Safe Home Referral Application
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.

To be placed in our program, applicants must meet the following criteria:
1. Female between the ages of 12 to 17
2. Resident of Virginia
3. Suspicion or confirmation of sexual exploitation in recent or past history

If you need any assistance, please contact us at 540-777-4663 or TLSreferrals@thelampstandva.org
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Child's Name (Last, First, Middle) *
Date of Birth *
MM
/
DD
/
YYYY
Place of Birth *
Is the Child anatomically female? *
Due to the nature of sex trafficking and the threat that male anatomy has historically posed to our participants, the program is only able to accept anatomically female participants. However, we wish to expand in the future.
Phone Number *
Race *
Height *
Weight *
Hair Color *
Eye Color *
Social Security Number *
Home Address *
How long has the Child lived in their present household? *
With whom is the Child currently living? *
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