1ninety-nine Referral Form

1ninety-nine Referral Form
I'm making this referral for:*

MyselfSomeone Else
Name of individual making referral:

First NameLast Name
Candidate's Legal Name*

First NameMiddle NameLast Name
Email*
example@example.com
Candidate's Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Is it OK to text?*

YesNo
Is Candidate presently or have previously been in a Restorative Care Program for survivors of Sex Trafficking?*

YesNo
If Yes, Please list all restorative care programs Candidate has attended and length of each stay.
Candidate's Age*
Candidate's Current City*
Candidate's Current State*

Street Address

Street Address Line 2

CityState

Zip Code
Candidate's Current Situation*
How quickly is Candidate seeking placement?*
Country of Nationality*

USAOther
What race/ethnicity do you identify as?

African AmericanAmerican Indian or Alaskan NativeAsian/Pacific IslanderCaucasian/WhiteHispanic/Latino(a)Other
What is Candidate's English Literacy*

FluentConversationalNone
Sex at Birth*
Current Gender Identity*
Has Candidate Been Verified as having been trafficked?*

YesNo
Please list trafficking verification (if applicable)*
Does Candidate have children?*

Yes, in candidate's custodyYes, but not in candidate's custodyNoYes, but children are grown and not in custody
Is Candidate Pregnant?*

YesNoUnsure
Does Candidate have drug/alcohol/marijuana use history?*

YesNo
Date of last use*

MonthDayYear
Date
Please check all mental health needs that apply to the candidate.*

diagnosed with psychosisHigh risk of relapseHigh suicidal ideationOn psychotropic medicationsPatterns of self-harmRequires a support animalRecent psychiatric hospitalizationRisk of runningUnable to self-manageViolent towards othersUnknownNone
Please List all Medical Needs that apply to Client*

EpiPenInhalerInsulin DependentPrescription MedsOTC Meds/supplements
Does Candidate have any disabilities that inhibit functioning?*

NoYes
Is Candidate Ambulatory?*

YesNoOther
Please list any chronic conditions. Ex.. diabetic, autoimmune disorder, chronic back pain, Hearing Impairment, Visual Impairment, Infectious Disease, other.....*
Do any of the following legal issues apply to the Candidate?*

Active Court CaseOn sex offender registryPending criminal chargesRequires parole/probation accountabilityRequires ankle monitoringUnder outstanding warrantUnknownNone
What level of supervision would be appropriate for the Candidate's needs?*
Internet/Phone use: *
Is Candidate aware and agreeable to being in a Christian/Faith-based program?*

YesNoUnsure
Please describe Candidate's Faith background*
Has applicant shown interest in the 1ninety-nine program?*

YesNoNot yet discussed with candidate
What is Candidate's annual income range (consider income from employment, TANF, food stamps and other sources)?*

$10,000 - $20,000$20,000-$30,000$30,000-$40,000Other
Candidate's Last Level of Education Completed*

Middle SchoolHigh SchoolVocational Training CertificateSome CollegeAssociate's DegreeBachelor's DegreeOther
If Vocational or College Degree, please list whether Candidate has been employed in area of training and for how long.
What duration of stay is the Candidate seeking?*
After review of this application, 1ninety-nine would like to schedule a phone or video informational call with the candidate. What is your preferred method of contact?*

phoneemail
Describe Candidate's Mental Health*
By submitting, I am indicating all my answers are true and accurate, to the best of my knowledge. (Please Sign Below)*
Please hit submit button when finished. We will contact you as soon as possible.
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