RUBY'S PLACE A PLACE FOR HOPE & HEALING

RUBY'S PLACE A PLACE FOR HOPE & HEALING
Referring Agency
Referring Service Provider
Email
Email
example@example.com
Service Requested:

RAFT ServicesHIS HouseFacilitated Peer Group
Date

MonthDayYear
Date
Peer Facilitated Group

Type option 1
Name
Contact Number
DOB
Current City
Preferred Language
Gender Identity
Is the client on:

ProbationParoleCurrently IncarceratedPreviously Incarerated
Has client experienced violence?

Yes - Please explain belowNoOther
Is client currently at risk for homelessness?

YesNo
Are reasonable accommodation required for client to receive services?

YesNo
If so, please describe
Any additional information you'd like to share with Ruby's Place Staff:
P: (510) 581-5626 F: (510) 581-5628 Crisis Line: (888) 339-7233

www.rubysplace.org

Ruby's Place is an innovative nonprofit committed to ending domestic violence, human trafficking, and violent crime, through hope, advocacy, and connection.
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