The Lampstand Safehome Eligibility Form
Thank you for making a referral to The Lampstand safehome! We look forward to speaking with you and hope we can make this process as smooth as possible for you and the youth you are assisting. If you need any assistance, please contact us at 540-777-4663 or TLSreferrals@thelampstandva.org
Referral and Family Information
Today's Date
*
/
Month
/
Day
Year
Name of Person Submitting this Form
*
First Name
Last Name
Your Phone Number
*
Your Email
*
Please describe your relationship with the Survivor on behalf of whom you are submitting this form:
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Parent/Guardian
Case Manager
Placement Coordinator
Probation Officer
Therapist
Family/Youth Advocate
Other
Agency Name (if relevant)
Your Title (if relevant)
From which county in Virginia are you making this referral? If referring for an out-of-state survivor, please type "out-of-state"
*
Custodial status
*
Please Select
Parental/ familial
Social Services
Law enforcement
Other
Where is the child currently located?
*
Back
Next
Survivor's Information
Please fill out the following information about the child who is being referred to The Lampstand safehome.
Survivor's name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
The Lampstand safehome only serves females ages 12-17
Is the child suspected to be a survivor of sexual exploitation or human trafficking?
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Yes
No
Unknown
Is the child safe where they located?
*
Yes
No
Unknown
Latest placement date:
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Month
-
Day
Year
Date
Please answer the following yes or no questions about the Survivor seeking services.
*
Rows
Yes
No
12-17 years old
Resident of Virginia
Biologically female
Has experienced sexual exploitation
A threat to self or others
Has a history of self-harming
In need of medical detox
Same-sex sex offender
Actively psychotic, suicidal, or homicidal
Has a history of fire setting
Has a history of gang recruitment
Believed to have IQ lower than 70
Does the child have any known developmental/intellectual disabilities or special needs?
*
Yes
No
Unknown
Please explain:
Any known safety concerns?
*
Yes
No
Unknown
Please explain:
Please note: The Lampstand is not a healthcare facility or drug rehabilitation facility.
*
I understand
Has the child recruited or shown interest or engaged in recruiting others into "the life"?
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Yes
No
Unknown
Please explain:
Is the child currently a flight risk?
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Yes
No
Unknown
Please explain:
Does the survivor have any known health or contagious disease concerns that we should be made aware of? (i.e. Diabetes, TB, etc.)
*
Yes
No
Unknown
Please explain:
Please upload any official documents or referral packets:
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