REFUGE FOR WOMEN                                      Resident Referral Request for Long-term Program
In an effort to best serve your potential applicant, we ask for you, her advocate or case worker, to give us some basic information on the woman you'd like to refer to our program. We prefer for her to have a warm handoff into our program. Someone from our National Intake team will contact you with next steps. Thank you!
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Your name *
Your title *
Your organization *
Your city *
Your state *
Your email address *
Your phone number *
Potential Applicant's Name (first name only) *
What is her age? *
Is she a US citizen? *
What is her current living situation? *
How long has she been at this location? *
Have you determined that she is a survivor of sex trafficking or commercial sexual exploitation? *
Please list all of her mental health diagnoses *
Please list all of her medical diagnoses and physical issues *
Please list all of her current medication *
Is she currently pregnant or have children under her custody? *
Does she have an eating disorder? *
Has she been diagnosed with a Spectrum Disorder (Autism or Asperger)? *
Is she able to exercise and climb stairs without assistance? *
Please list all drugs ever used *
When was her last use? *
Does she drink alcohol? *
When was her last drink of alcohol? *
Is she in need of detox? *
Does she have any open warrants (in any state)? *
Is she currently on parole or probation? *
Does she have any pending court dates? *
Is she open to a faith-based program? *
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