Client/Guardian has been notified of referral?* YesNo Potential Client Info*: Legal First Name Legal Last Name Legal Middle Name Name Street Zip Code Phone Number Email Address Preferred Language Parent/Guardian Info*: Legal First Name Legal Last Name Legal Middle Name Name Street Zip Code Phone Number Email Address Preferred Language 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 3. Who is the youth currently living with (If in custody provide release date): 4. Has the potential client participated in another program and why are they seeking to participate in the GRACE Program?* YesNo 5. Potential client interested in receiving services?* YesNo 6. Services Youth Is Interested In (check all that apply):* MentorshipSupport GroupsFaith-based ServicesToiletriesTransportationMeal SupportEducation SupportEmployment SupportHousing SupportParenting Support 7. Additional Resources Needed Referring Person's Info*: Legal First Name Legal Last Name Legal Middle Name Name Phone Number Email Address Referral Date*: Δ
