Instructions: Please complete this form in its entirety to assist us in providing a quick response. Upon completion, please be sure to click the "Submit Referral Form" button below. FAIR Girls will respond to your referral within 24-48 business day hours from receipt. If you have any questions or concerns, please reach out to FAIR Girls at info@fairgirls.org. If you have an immediate question or concern, or would like assistance in completing this form, please contact our 24/7 Crisis Referral Line at 1(855) 900 3247.Referrer InformationName* First Last Email* Contact Phone Number*Job Title Client InformationName* First Last Birthdate MM slash DD slash YYYY Location Phone NumberEmail Social Media Which of the following best describes the client?* Asian Black/African-American Caucasian/White Hispanic/Latinx Native American Pacific Islander Prefer not to answer Other Describe ethnicity: Which of the following best describes the client?* Female Male Non-binary Prefer not to say Other Please describe: Does the client have children?* Yes No Does the client have children with them?* Yes No If client is a youth, legal guardian name: If client is a youth, legal guardian contact information: If client is a youth, what school do they attend, and what is their highest grade completed: FAIR Girls works with any female-identifying individual who identifies as a trafficking victim, or who has experienced exploitation in commercial sex or labor/work. Anyone under the age of 18 that is involved in commercial sex is considered a victim of sex trafficking, and anyone over 18 who has been threatened, forced, or tricked into engaging in commercial sex activities is also a trafficking victim. Commercial sex might include the following activities: prostitution, stripping, and escort services. Someone who is a victim of labor trafficking may have been forced to work as a domestic servant in a home, made to work in sweatshops, may not be getting paid fairly or at all, and may have threats against them and their documents taken. If you're unsure whether or not your situation falls under trafficking, that's okay; you can just provide as much detail as possible below.Suspected or Confirmed Human Trafficking (Labor or Sex) or CSEC :*Check all that apply Suspected Sex Trafficking Suspected Labor Trafficking Confirmed Sex Trafficking Confirmed Labor Trafficking Commercial Sexual Exploitation of Children (CSEC) Not sure Other Please describe: If suspected, what is the reason?Check all that apply. Please note: circling boxes does NOT disqualify you/your client from receiving services. We just want to ensure that we know how best to support the client. History of Child welfare involvement History of Sexual Abuse History of Gang Involvement History of Domestic Violence History of Mental Health History of Substance Abuse History of incarceration Client is on probation Current court involvement N/A If there is a history of mental health issues, please list diagnosis:If there is a history substance abuse, please list substances:Is the client in HOPE Court?* Yes No If so, who is the probation officer? Please include any contact information (i.e. phone, email) Is client CFSA/CPS involved?* Yes No If so, who is the assigned case worker/social worker? Please include any contact information (i.e. phone, email) Are there any current health concerns? If so, was the client hospitalized and for how long?*Please choose services interested:* Vida Home Case Management Drop-in Center Access Other: Describe other services: If connected with other services, please list organizations and services provided: Please include any other important information: FAIR Girls AdminReferral Form10.08.2020
