Traffick911 Referral Form

Voice & Choice Advocate Referral Form
Completion of this form does not guarantee provision of services. Services may be based on current capacity and caseloads in order to continue to provide the highest level of care and excellence to the families and clients we serve.
Name of Individual Making Referral*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Name of Organization/Government Agency*
If applicable
County where Organization/Government Agency is Located*
Youth Information
CSE-IT Score*
If no CSE-IT has been completed, please put "0"
If no CSE-IT has been completed, please state reason below:
Select all that apply*

Youth is a confirmed victim of sex trafficking.Youth has runaway three times or more in a nine (9) month period.Youth is 13 years of age or younger and is missing or has runaway.Youth has been a runaway for over 30 consecutive days, but is not currently a runaway.Youth has a CSE-IT score of clear concern (9 or above).Youth has two or more separate incidences of sexual abuse and/or exploitation in a 12-month period.
Youth's Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Race/Ethnicity*
Gender*
Youth's Phone Number
If applicableFormat: (000) 000-0000.
PID Number
If applicable
Youth's Current Location*
Projected Length of Placement/Detainment
e.g. release date, upcoming court date, recommended disposition
Youth's trafficking/ exploitation history*
Please attach CSE-IT or any other relevant documentation.

Cancelof
Guardian Information

If primary custody of youth is DFPS, please leave this section blank by putting "n/a" or "0"s and provide this information under the "Parties Involved" and "DFPS Involvement" sections of the referral form.
Legal Guardian's Name*

First NameLast Name
Guardian's Relationship to Youth*
Guardian's Phone Number*
Format: (000) 000-0000.
Guardian's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian's Primary Language*
Is guardian aware of this referral submission?*
It is strongly recommended that the guardian is aware of the referral prior to or at the time of the referral. Notification of the referral will allow for a more effective intake process.
Education History
Is youth currently enrolled in school?
Last grade completed
Name of School
City of School
Notes on education
Mental Health History
Current Psychiatric Diagnoses
Current Medications
Has the youth had any past suicide attempts?
If yes, please provide number of attempts and any other relevant information.
Has the youth ever exhibited aggressive and/or violent behavior?
Includes homicidal ideation
If yes, please any other relevant information.
Does the youth have a history of psychiatric hospitalization?
If yes, please provide dates and locations if known.
Triggers/Precautions
Specific to suicidality, maladaptive behaviors, disassociation, aggression, etc.
Drug History
Does the youth have a history of drug/substance abuse?
If yes, please provide length of time and types of drugs if known.
Any additional notes regarding youth's drug/substance use:
Runaway History
Number of times youth has runaway
Approximate and/or reported
Any additional notes regarding youth's runaway history:
Parties Involved
Please select the parties involved with the youth:*

Probation OfficerDFPS CaseworkerInvestigating Law Enforcement ContactAttorneyCASAGuardian Ad LitemTherapist/CounselorNoneOther
Probation Officer

If applicable
Probation Officer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Probation Officer's Email
example@example.com
DFPS CPI/CPS Caseworker

If applicable
DFPS CPI/CPS Caseworker's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
DFPS CPI/CPS Caseworker's Email
example@example.com
Investigating Law Enforcement Contact

If applicable
Investigating Law Enforcement Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Investigating Law Enforcement Contact's Email
example@example.com
Attorney

If applicable
Attorney's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attorney's Email
example@example.com
Please indicate which attorney's information you are providing:

ProsecutorPublic Defender
CASA

If applicable
CASA's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
CASA's Email
example@example.com
Guardian Ad Litem

If applicable
Guardian Ad Litem's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Ad Litem's Email
example@example.com
Therapist/Counselor

If applicable
Therapist/Counselor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Therapist/Counselor's Email
example@example.com
Additional service provider(s) and contact information:
Department of Family Protective Services (DFPS) Involvement
Is there a DFPS case currently open?*
State of DFPS Service
Investigation Disposition
Type of Conservatorship
Has there been a DFPS case open in the past?
Investigation Disposition
Any additional notes regarding DFPS/CPS history or status
Additional Services
In an effort to not duplicate services and efforts, please list any other recent service providers and/or professionals in the youth or family's life:
If you have any questions, please email our Intake Coordinator at intake@traffick911.com.
Should be Empty:

Youth Information

Guardian Information

Education History

Mental Health History

Drug History

Runaway History

Parties Involved

Department of Family Protective Services (DFPS) Involvement

Additional Services