CEATT Inc. - Referral Form

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If you or someone you know has experienced trauma—including but not limited to gun violence—please consider making a referral today. You may refer yourself, a loved one, or a potential client who could benefit from our no-cost trauma-focused services.

Let me know if you'd like to refine it further!

Referral Source Name: *

Self-Referral

Hope For Communities

Genesis Hopeful Haven

Global Speech and Rehab Services

City of Miami Police Department - Victim Advocate Services Program

Miami Dade County Public Schools

Miami Dade Police Department - Victim Advocate Services Program

Miami Gardens Police Department - Victim Advocate Services Program

Miami Beach Police Department - Victim Advocate Services Program

North Miami Police - Victim Advocate Services Program

The Alternative Program

Other:

Referral Source Email: *

Referral Source Best Contact Number: *

Florida Residents--County of Residence: *

Miami-Dade

Monroe

West Palm Beach

Broward

Other:

Required

What types of trauma have you or the person you are referring DIRECTLY and/or INDIRECTLY experienced? (Select all that apply): *

Gun violence

Domestic violence

Sexual assault or abuse

Child abuse or neglect

Human trafficking

Community violence (e.g., gang violence, neighborhood crime)

Racial or cultural trauma

Immigration trauma (e.g., displacement, family separation, asylum-seeking stress)

Natural disaster trauma (e.g., hurricanes, earthquakes, floods)

Medical trauma (e.g., life-threatening illness, medical procedures)

Substance abuse-related trauma (self or family-related)

Incarceration-related trauma (self or family-related)

Military-related trauma (combat exposure, family member deployment)

Loss of a loved one (grief-related trauma)

Intimate partner violence

Other:

Required

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