Form - GRACE

Girls Rising Above Child Exploitation (GRACE) Referral Form

619.499.4959

GRACE serves youth and TAY ages 12-24 who have been trafficked, exploited, or at-risk.
Please mark below the services the youth and/or family are interested in.

GRACE staff are NOT licensed mental or health care professionals. GRACE is not responsible for mental health services nor any physical or mental health concerns. Mental/physical health services should be sought out by the client separately, if needed.

Before making a referral, please be sure youth are aware that a referral is being made
and that they are informed of the population we serve. GRACE services are voluntary.

Client/Guardian has been notified of referral?*
Client/Guardian has been notified of referral:
YesNo

Potential Client Info*:

Parent/Guardian Info:

Screening Questions*:

1. Has the potential client experienced/currently experiencing trafficking/exploitation or considered to be high-risk? (See below for examples)
- ie: has someone who gets them in contact with people to have sex (i.e. pimp, trafficker, “boyfriend” or “girlfriend”)
- ie: has relatives or friends who have been known to exchange sex for anything (i.e. money, place to stay or food)
- ie: experienced truancy, homelessness, substance abuse, sexual assualt (self or family), domestic violence (self or family)
- ie: sends or posts provocative photos of self, history of running away/AWOL, currently in foster care*
YesNo

2. Is the potential client currently suffering from any of the following (selecting 'yes' will require a referral for additional services) Substance abuse (drugs or alcohol), domestic violence, homelessness?*
YesNo

4. Has the potential client participated in another program?*
YesNo

6. Potential client interested in receiving services?*
YesNo

Referring Person's Info*:

Referral Date*:

[recaptcha]

Girls Rising Above Child Exploitation (GRACE) Referral Form

[email protected]

www.girlsrisingabove.org

619.499.4959