Referral and Family Information
Today's Date
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 /
Month
 /
Day
Year
Name of Person Submitting this Form
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First Name
Last Name
Your Phone Number
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Your Email
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Please describe your relationship with the Survivor on behalf of whom you are submitting this form:
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Parent/Guardian
Case Manager
Placement Coorinator
Probation Officer
Therapist
Family/Youth Advocate
Other
Agency Name
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Your Title
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From which county in Virginia are you making this referral? If referring for an out-of-state survivor, please type "out-of-state"
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When is the best time we can contact you about this referral?
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Morning (9AM - 12PM)
Afternoon (12PM - 5PM)
Evening (5PM - 8PM)
Anytime
Parent/Guardian's Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian's Email Address
Parent/Guardian's Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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The Lampstand Safehome Referral Form
Thank you for making a referral to The Lampstand safehome! We look forward to speaking with you and hope we can make this process as smooth as possible for you and the youth you are assisting. If you need any assistance, please contact us at 540-777-4663 or TLSreferrals@thelampstandva.org
Survivor's Information
Please fill out the following information about the child who is being referred to The Lampstand safehome.
Survivor's Name
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First Name
Last Name
Current Age of Survivor
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Please Select
12
13
14
15
16
17
The Lampstand safehome only serves females ages 12-17
Do you know the survivor's date of birth?
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Yes
No
What is the current custodial status of the youth?
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Dependency and Neglect
Juvenile Justice / Custody
Juvenile Justice / Probation
Family Support Services
Family Crisis Intervention Program
Non-Custodial (Private Placement)
Other
Do you know if the Survivor recognizes the trauma they have experienced and identifies as a victim of sexual exploitation or trafficking?
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Yes
No
Unknown
Has your client been identified as a survivor of sex trafficking?
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Yes
No
Unknown
What is the current placement of the Survivor?
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Length of time in this location:
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Less than 3 months
3-6 months
6-12 months
12+ months
Other
Is the Survivor safe where they located?
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Yes
No
Unknown
How long can the Survivor stay in this location? (In the event we have a waitlist, etc.) Please explain:
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List all current and previous placements in the last year and reasons for leaving:
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Please answer the following yes or no questions about the Survivor seeking services.
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Rows
Yes
No
12-17 years old
Resident of Virginia
Biologically female
Has experienced sexual exploitation
A threat to self or others
Has a history of self-harming
In need of medical detox
Same-sex sex offender
Actively psychotic, suicidal, or homicidal
Has a history of fire setting
Has a history of gang recruitment
Believed to have IQ lower than 70
What are the Survivor's main symptoms/concerns?
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Panic Attacks
Low Self-Esteem
Suicidal Ideations
Fatigue
Anxiety and Fear
Self-Harming
Depression
Antisocial Behaviors
Trauma Bond
Language and Cognitive Difficulties
Sleep Disruption
Unknown
Other
Any known mental health issues?
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Yes
No
Unknown
Do they have any known developmental disabilities or special needs?
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Yes
No
Unknown
Any known safety concerns?
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Yes
No
Unknown
Do they have a criminal history
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Yes
No
Unknown
Please explain history above:
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Please list any case workers or therapists they currently have:
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Does the Survivor have an IEP (Individualized Education Program) or 504?
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Yes
No
Unknown
Any known health or contagious disease concerns we should be made aware of? (i.e. Diabetes, TB, etc.) Please explain:
*
Is the location of the trafficker known?
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Yes
No
Unknown
Do you know if their trafficker used drugs as a form of control?
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Yes
No
Unknown
Has there been drug use that would cause them to need detoxification prior to coming to The Lampstand?
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Yes
No
Unknown
Please note: The Lampstand is not a healthcare facility or drug rehabilitation facility.
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I understand
Are there are known threats of violence or retaliation by their trafficker/family/significant other?
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Yes
No
Unknown
Have they recruited or have they shown interest in recruiting others into "the life"?
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Yes
No
Unknown
Are they currently a flight risk?
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Yes
No
Unknown
What are their safety and security needs?
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Additional information or comments:
Does the Survivor know you are making a referral to The Lampstand?
*
Yes
No
Please upload any official documents or referral packets:
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SETTS Quick Screen
Please complete the Sexual Exploitation Treatment and Training Services Quick Screen below:
Has the child run away three or more times in the past three months?
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Yes
No
Are there concerns regarding the child's peer groups (i.e. drugs, gangs, older peers)?
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Yes
No
Are the child's whereabouts being accounted for?
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Yes
No
Is there a presence of unexplained gifts or items, such as phones, shoes, money?
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Yes
No
Does the child have a history of substance abuse, abuse, exploration?
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Yes
No
Does the child exhibit changes in mood (i.e. angry, sad, emotional, etc.)?
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Yes
No
Does the child have a history of experiencing abuse (physical, sexual, etc.)?
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Yes
No
Does the child have physical injuries with no explanation?
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Yes
No
Has the child been unsafe on the internet (display of sexual suggestiveness)?
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Yes
No
Are self-harm, eating disorder(s), suicidality, and/or aggression present in the child's life?
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Yes
No
How was this information verified?
*
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SUBMIT
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