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HEALING AND JUSTICE CENTER | TRC Referral Form
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Email
*
Your email
Today's Date
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YYYY
Name of Person Completing this Form
Your answer
Your Phone Number
Your answer
Your Email
Your answer
Agency and/or Department
Peacemakers
Youth Programs
Freedom House Mobile Crisis
Doctors within Borders Clinic
Touching Miami with Love
Circle of Brotherhood
Dream Defenders
Other:
Client's Name
Your answer
Client's Date of Birth
MM
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YYYY
Client's Address
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Client's Phone Number
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Client's Email
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Client's Race
Black
Latinx
Asian/Pacific Islander
Native American
Mixed Race
White
Declines/Unkown
Other:
Preferred Language
English
Spanish
Native American
Other:
Are you presently employed?
Yes
No
Other:
Are you a military veteran?
Yes
No
Other:
Do you have an emergency contact?
Yes
No
Other:
Clear selection
If yes, who are they? (Name and relationship)
Your answer
What is their phone number?
Your answer
Have you experienced trauma?
Yes
No
Other:
Clear selection
If YES, please select all that apply from the list below:
Sexual Assault
Domestic Violence
Physical Assault
Stabbing
Shooting
Vehicular Assault
Family of a victim
Refugee/Outside of the US trauma
Other:
Are you currently taking any medication?
Yes
No
Other:
Clear selection
If yes, please list your medications below:
Your answer
When are you available for an assessment?
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YYYY
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