Need Immediate Help? | Daughters of Worth

Date

Month

Day

Year

This referrals is being provided by:

Organization working with a survivor

Myself (survivor)

Other

If other, please define the relationship:

Full name of individual providing the referral

Full name of survivor needing assistance:

Contact information for the survivor:

Is it safe for Daughters of Worth to contact the survivor?

Yes

No

Uncertain

What is the best method and timeframe for DOW to contact the survivor?

Survivor's Date of Birth

Month

Day

Year

Where is the survivor currently located? City and state?

Address of the survivor (if known)

Does the survivor meet the criteria for identification as a trafficking victim? (Being compelled by the use of force, fraud, or coercion to conduct commercial sex acts?)

Yes

No

Uncertain

Is the survivor supportive of this referral, desiring assistance?

Yes

No

Uncertain

Is the survivor currently safe?

Yes

No

Uncertain

Explain what has happened that has led to the survivor seeking assistance and what services are needed:

Does the survivor have children?

Yes

No

Uncertain

If the survivor has children, are they in her custody?

Yes

No

Uncertain

If the survivor has children, what are the ages of the children?

Is the survivor in need of detox or inpatient services for substance use disorder?

Yes

No

Uncertain

If the survivor needs detox/inpatient services, what are the drugs of choice and when is the last time that she used? How much?

If relocation services are needed, is the survivor willing to relocate out of state?

Yes

No

Uncertain

Any additional information that is relevant for Daughters of Worth team to know regarding the survivor and request for services:

Signature

Signature field is empty.

Email of the individual providing referral

Phone number of the individual providing referral