Safe Space Carolinas Referral & Assistance Request Form

Safe Space Carolinas Referral & Assistance Request Form

Please fill out this form to request help or refer someone for support in South Carolina. Have relevant details ready.
Emergency Notice, Referral Source, and Referrer Details
Emergency notice acknowledgement
Referral source type

Other
Referrer name

First NameMiddle NameLast Name
Organization name
Role or title
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred contact method
Relationship to the person or family
Person or Family Being Referred
Full Name of Person Being Referred

First NameMiddle NameLast Name
Preferred Name
Age or Date of Birth
Is a Child or Minor Involved?
Parent or Guardian Name(s)

First NameMiddle NameLast Name
Household Composition
County
City
Address, if safe and appropriate to collect

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Safe Contact Instructions and Preferred Contact Methods
Is it safe to contact the referred person or family directly?
Reason for Referral and Assistance Requested
Reason for Referral

Other
Assistance Requested

Other
Urgency Level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is Critical
Describe the situation
Risk indicators present

Other
Other assistance details
Consent, Authorization, Privacy, and Legal Notices
I consent to sharing the following personal identifying information with partner organizations, affiliates, service providers, funders, agencies, and community partners

Other
Who may receive shared information
Information sharing preference
I agree that all information provided is truthful and complete to the best of my knowledge
Consent decision
Uploads, Signatures, and Submission
Supporting Documents

Cancelof
Identification Documents

Cancelof
Court, Agency, School, Medical, Benefits, or Housing Documents

Cancelof
Referrer Signature
Parent/Guardian or Adult Client Signature (if available)
Signature Date and Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Safe Space Carolinas Referral & Assistance Request Form

Emergency Notice, Referral Source, and Referrer Details

Person or Family Being Referred

Reason for Referral and Assistance Requested

Consent, Authorization, Privacy, and Legal Notices

Uploads, Signatures, and Submission