COMMUNITY REFERRAL FOR VICTIMS OF SEX TRAFFICKING
LIGHTHOUSE FOR LIFE
REFERRING AGENCY INFORMATION
Date
Agency making referral
Contact name
Position/Title
Phone
Email
example@example.com
REFERRAL INFORMATION
Name/Initials
Sex at Birth
Pronoun
She
He
They
Age
Phone
Email
example@example.com
Yes
No
Okay to call?
Okay to text?
Okay to email?
Location
TRAFFICKING INFORMATION
Type of trafficking
Sex
Exploitation
Labor
Current Needs/Situation:
Additional Comments:
lighthouseforlife.org | 803-900-1811 I survivor.support@lighthouseforlife.org
Submit
Should be Empty: