Elijah Rising Restoration Program Referral Form
Applicants may be referred to Elijah Rising Restoration Program by a variety of sources, however they must all fill out the online client referral form.  Referral agencies may include law enforcement, shelters, trafficking hotlines, substance abuse treatment centers, other nonprofit organizations, and more.  All applicants will require interviews and proper intake procedures.

The online client referral form will be followed up by a phone call from the Program Director.  If it is determined that the applicant and Program Director are agreeable to moving forward, a full application will be sent to the applicant and an interview will be scheduled.

Sign in to Google to save your progress. Learn more
Referring Agency *
Referring Agent's Name *
Referring Agent's Phone *
Referring Agent's Email Address *
What is your relationship to the person you are referring? *
Does the person you are referring have your consent to complete this form? *
Program Candidate's Name *
Candidate's Current Phone Number(s) *
Candidate's Email Address *
Candidate's Date of Birth *
Is the candidate biologically female? *
Address or Current Living Situation *
Does she have children in her custody, with family, or with Child Protective Services? *
Is it possible this candidate is currently pregnant? *
Is the candidate on probation, parole, or have any open criminal warrants? *
Does the candidate have a history of addiction via substance abuse? *
If the candidate has a history of addiction, what was/ is her drug of choice? *
How many days clean does the candidate have, if any? *
Is the candidate currently on prescription medications? *
Please list the medications, if known.
Is the candidate a victim on commercial sexual exploitation? *
Does/ did / did she have one or multiple pimp(s)/ trafficker(s)? *
What are her immediate medical needs? *
Have you discussed the Elijah Rising Restoration Program with this person? *
Has she been prescribed pharmacology for medical or mental health concerns? *
Would you consider this client a low, moderate, or high flight risk? *
Is she currently incarcerated, on parole, or probation? If yes, please explain. *
What is your preferred method of communication?
Clear selection
Clear form
Never submit passwords through Google Forms.
This form was created inside of Elijah Rising. Report Abuse