Youth Referral Form
Please fill out this form to refer a minor.
Your Full Name
*
First Name
Last Name
Your Email Address (if you do not have an email, please write N/A)
*
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your relationship to the Youth you are referring?
*
Friend or family
Hospital or medical staff
Law enforcement
DCS
Court Advocate
Social service agency staff
Other
Guardian Information
Guardian of the Youth being referred (if youth is in DCS custody please put their case manger or best point of contact for their care)
*
First Name
Last Name
Email Address of Guardian (If they do not have an email please write N/A)
*
Phone Number of Guardian
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the guardian aware that this referral was made
*
Yes, they are aware
No, they are not aware
Is it safe to contact the guardian?
Yes
No
Information on Who is Being Referred
Full Name of Youth Being Referred
*
First Name
Last Name
Does the Youth have a preferred different name?
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender non-conforming
Does not know
Other
Please specify youth's gender
*
What language does the youth most comfortably speak?
*
Race/Ethnicity
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other pacific Islander
White
Hispanic/Latino
multiple
Other
Please specify your race/ethnicity
Does the Youth Identify as any of the following (please select all that apply)
*
Deaf/Hard-of-hearing
Homeless
Immigrant/Refugee/Asylum seeker
LGBTQ+
Someone with Disabilities: Physical/Cognitive/Mental
Limited English Proficiency
None of the above
Preferred pronouns
*
What school does the youth attend?
*
What grade is the youth in?
*
What address does the youth reside at?
*
Currently located
*
Please Select
Cheatham
Clay
Davidson
Dickson
Giles
Hickman
Houston
Humphreys
Jackson
Lawrence
Lewis
Macon
Marshall
Maury
Montgomery
Overton
Perry
Pickett
Putnam
Robertson
Rutherford
Smith
Stewart
Sumner
Trousdale
Warren
Wayne
Williamson
WilsonIn
TN but not listed
Out of State
Please specify location
Trafficking History
Please select what forms of trafficking or risky behaviors the youth may have experenced
*
Sex Trafficking
Labor Trafficking
Sex and Labor Trafficking
Child Sexual Exploitation Material (CSEM)
High Risk
Please give a description of why CSEM, Sex or labor trafficking is suspected/confirmed for this youth.
*
Are there known persons suspected in being involved in the youths trafficking?
*
Is Law enforcement currently involved?
*
Yes
No
Unknown
Law enforcement's name and contact information
Does youth have a history of running away? If so please describe past incidents.
*
Needs
Does the youth receive services from other providers (This could be case management, therapy services, groups, mentorship etc. )
*
Yes
No
Please list the name of the organization and the contact info for that organization
*
Please select immediate needs that the youth may have.
*
Academic Support
Employment/Life Skills
Mental Health Treatment
Behavior Modification
Substance Abuse Treatment
Basic Needs
Mentoring
Case Management
Spiritual/Social Support
Other
Please specify other immediate needs
Is there anything else that would be helpful for us to know when working with the youth and their family?
Safety concerns
Are there any safety concerns for the child being in the home?
*
Are there any known triggers for youth? If yes, please list them
*
Please list all locations the youth is NOT permitted to go:
*
What services are you requesting from AncoraTN? (All support requests are subject to eligibility determination)
*
Report Only (DCS Mandate)
Case Management & Advocacy (Confirmed History of CSEM or Trafficking)
Prevention (At Risk)
Not sure
Please upload any relevent files to the referral
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