The Helianthus Project

The Helianthus Project

Secure Referral Form
Thank you for contacting The Helianthus Project.

This secure form is intended for individuals seeking help for themselves or for professional and community members making a referral for someone else. All referrals are reviewed by our team. Submission of this form does not guarantee services.

If someone is in immediate danger, call 911 before submitting this referral.
Section 1

Who Are You?
I am...
Section 2

Your Contact Information
Name

First NameLast Name
Organization (if applicable):
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact method
Section 3

Person Needing Assistance
Name

First NameLast Name
Age
County
Current City
Preferred Language
Safe Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Safe Email
example@example.com
Section 4

Immediate Safety
Is the individual currently in immediate danger?
If someone is in immediate danger, please call 911 before continuing.
Section 5

Why Are You Contacting Us?
Select all that apply:

Other
Section 6

Tell Us About the Situation
Please describe what is happening and why you are requesting/referring assistance. Include ONLY the information necessary to help us understand the situation. A member of our team will reach out directly.
Section 7

Immediate Needs
Check all that apply

Other
Section 8

Is Law Enforcement Involved?
If Yes, please write Agency, Officer, Case Number (if applicable)
Section 10

Consent
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

The Helianthus Project

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