First Light
Partner Referral & Program Fit Form
First Light is a nonprofit providing structured, non-clinical community support for women navigating life after trauma, crisis, or long-standing survival patterns. We do not provide therapy, crisis intervention, or emergency services.
This form helps determine whether First Light Circles are an appropriate next step for the referred participant.
Important:
First Light is a nonprofit organization providing structured, non-clinical community support. We do not provide therapy, crisis intervention, emergency services, or case management.
This referral form is used solely to determine program fit. If a participant is experiencing an emergency or acute mental health crisis, please contact 911, 988, or appropriate crisis services prior to referral.
1. Participant Information
Full Name:
Preferred Name (if different):
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Age Range:
18-24
25-34
35-44
45-54
55+
Preferred Method of Contact:
Email
Phone
Text (if appropriate)
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Is it safe to contact the participant at the information provided?
Yes
No
Unsure
If no or unsure, please provide safe contact instructions:
2. Referral Source
Referring Organization:
Referring Staff Member (if applicable):
Has the participant been informed that First Light is a non-clinical community program?
Yes
No
Reason for referral (check all that apply):
Post-crisis stabilization support
Aftercare following therapy
Support after domestic violence services
Support after sexual trauma services
Emotional regulation skill-building
Accountability and structured peer support
Rebuilding self-trust and stability
Other
3. Current Support Status
Is the participant currently connected to any of the following?
Individual therapy
DV/sexual assault advocacy services
Psychiatric care
Case management
Not currently connected
Unsure
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First Light works best alongside clinical or crisis services when needed.
4. Safety & Program Appropriateness Confirmation
First Light is a non-clinical, community-based program and is not equipped to provide crisis intervention or manage acute mental health concerns.Please confirm the following:
The participant is not currently in immediate danger requiring emergency services.
The participant is emotionally stable enough to participate in a structured group environment.
Any acute safety concerns have been addressed through appropriate clinical or crisis channels.
The participant understands that First Light does not provide therapy, crisis response, or case management.
If there are current safety considerations we should be aware of for group facilitation purposes (without clinical detail), please note here:
5. Areas of Growth & Integration
Which themes are most relevant to the participant's current season?
Which themes are most relevant to the participant's current season?
Difficulty maintaining progress after therapy or crisis services
Repeating relational patterns
Struggles with boundaries
Emotional reactivity or shutdown
Identity confusion after trauma
High-functioning but feeling stuck
Desire for structured accountability
Isolation or lack of supportive community
Other
In a few words, what does the participant hope will change in her life?
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6. Program Understanding
Please confirm the participant understands:
First Light Circles are non-clinical and educational
Circles do not provide therapy or crisis response
Participation requires emotional stability appropriate for group settings
The focus is skill integration, accountability, and peer support
7. Additional Notes for Matching
Anything helpful for circle placement (scheduling needs, identity considerations, etc.):
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