REFERRAL FORM Potential Client's Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Potential Age Contact Number (Of potential client) (###) ### #### Name of person referring First Name Last Name Phone Number of Person Referring (###) ### #### Potential Client Is: Male Female Is It Safe to Contact Potential Client Yes No Reasons for Referral: (Check ALL that apply) Admits to being "In the Life" or the Commercial Sex Industry Noticeably "In the Life" or Commercial Sex Industry Obvious Red Flag Behavior Known Human Trafficking Case Has a Pimp of Possessor Other Do You Represent: Agency Self Safe House - Shelter Law Enforcement Anti-Trafficking Task Force Court Official Social Services Friend/Family Member Other Sessions you plan to participate in: Shelter Medical Assistance Identification Assistance Counseling/Therapy Job Search Support Educational Support Legal Assistance Advocacy Any additional information: Thank you for your referral submission. We’ll be in contact soon.
