Refuge City Referral Form 2025

Refuge City Referral Form
1. Referred By
Name of person making referral*

First NameLast Name
Relationship to referred youth*
Referring Agency Name*
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
2. Youth's Information
Name *

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Phone Number (if applicable)
Format: (000) 000-0000.
Age*
Primary language spoken*
When is the youth available to start in Refuge City’s program?*
Is this youth currently on probation?*

YesNo
What is the name of this youth’s probation officer?*
What is the projected date of probation completion?*
3. Parent/Guardian Information
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian’s primary language*
Who does this youth live with?*
Relationship to Youth*
4. Specific Information
Is this youth a confirmed trafficking survivor?*

YesNo
Has the youth experienced sexual exploitation of any kind?*

YesNo
Please explain known details of the situation(s)*
Does this youth have a history of runaways?*

YesNo
How many runaways in the last 12 months?*
Did runaways start before the age of 13?*
Approximately how many times has this youth ran away in the past 12 months?*
CSE-IT score?*
Any knowledge of childhood sexual abuse?*
How recently was she/ he in a trafficking or exploitation situation?*
Check all agencies that are involved in this case.*

Law EnforcementProbation OfficerTraffick911CPSJuvenile JusticeChild Advocacy CenterSocial WorkerOther
Please list the name, phone number and email address for the contact on this case at each agency checked above.*
In an effort to not duplicate services and efforts, please list any other recent service providers and/or professionals in the youth or family's life. *
Is there any other relevant information that you would like us to know?*
5. Education
Is the youth currently enrolled in school?*

YesNo
If so, where?*
What is the youth's last grade completed?*
Is this youth interested in our GED program?*

YesNo
6. Health
Please explain youth’s history of self-harm, if any.*
Has the youth ever attempted suicide? If so, please explain their history of suicidal behaviors.*
Substance abuse history:*
Has the youth ever participated in violent or aggressive behaviors? If so, please explain their history of these behaviors:*
Does this youth have a history of psychiatric hospitalizations? If so, please provide dates and causes of hospitalization:*
For female youth: has this youth ever been or is currently pregnant?*
Please upload all related files and reports (Refuge City has a memorandum of understanding with Traffick911 and Dallas County Juvenile).

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Refuge City Referral Form

1. Referred By

2. Youth's Information

3. Parent/Guardian Information

4. Specific Information

5. Education

6. Health