POETIC Referral Form
POETIC is an in-community aftercare program for girls (12-18) who have experienced child sexual abuse, commercial sexual exploitation (CSE) or domestic minor sex trafficking (DMST).

This form is to be used by Dallas County Juvenile Department and be filled out by a probation officer and/or therapist from the county.

Filling out this form indicates that the youth referred has already been deemed eligible for POETIC services and the following documents have already been sent and reviewed:

Previous psychological evaluation(s) (PSAS)
Probation report
Educational records
Discharge Summary

Please fill out the following information so that an intake with the youth and guardian can be scheduled for consideration in to the POETIC program.

Email address *
First Name of Youth Being Referred *
Your answer
Last Name of Youth Being Referred *
Your answer
Youth Date of Birth of Youth *
MM
/
DD
/
YYYY
Race/Ethnicity *
Required
CPS Placement History? *
Does youth have a history of childhood sexual abuse/sexual assault? *
Does youth have a history of physical abuse/neglect? *
Does youth have a history of domestic/family violence? *
Does youth have a history of Commercial Sexual Exploitation (CSEC)? (History or suspicion of sexual activity in exchange of anything of value such as housing, food, drugs, promise of safety, etc) *
Does youth have a history of Sex Trafficking? (History or suspicion of sexual activity in exchange of anything of value where a third party profits such as a trafficker, recruiter, "boyfriend," family member, etc) *
Has youth ever violated a court order? *
Has youth ever experienced homelessness? *
Does the youth identify as LGBTQ? *
Is youth aware you are making the referral? *
Guardian Name *
Your answer
Guardian Address *
Your answer
Zip Code she will likely return home to *
Your answer
Guardian Phone Number *
Your answer
Guardian Email address (if known)
Your answer
PO's field office or Therapist location *
Your answer
PO or Therapist number *
Your answer
Date Probation Ends (or ended) *
MM
/
DD
/
YYYY
Where is the youth at the present time? *
If in placement - estimated discharge date
MM
/
DD
/
YYYY
POETIC Services Referring to (you may select multiple) *
Required
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This form was created inside of POETIC.