Send A Referral

Alliance Referral Form Overview

We at NTSA are here to help you find residential services for recovery from trafficking or sexual exploitation. This form collects some basic information on your needs and preferences to better help us do that.

By completing this referral form, you are agreeing to allow the National Trafficking Sheltered Alliance to share this information with our referral system network of service providers, for the purpose of finding you appropriate services. This form must be filled out completely before submission. ALL INDIVIDUAL INFORMATION WILL BE KEPT CONFIDENTIAL within the Alliance network. You will be contacted directly by any agency that has availability and is able to consider you for placement. ARS will not replace the assessment process of individual agencies; we are a facilitator only.

We or our partners may publicly share aggregated information such as trends in survivors’ needs when doing so helps us advocate for survivors as a group. We will never publicly share information about individuals.

We commit to matching your referral to the appropriate residential programs in our system within 24 hours during business days.

We are not an emergency service, so if this is an emergency please contact 911 or the human trafficking hotline at 1(888) 373-7888.

As you begin...

This form can be filled out by yourself or by an advocate representing the individual needing services. Please answer all questions to the best of your ability, and indicate “Not Applicable” (N/A), or provide an alternative answer if necessary. Services are searched for according to the answers given below, so answering honestly will better help us find appropriate matches.

*PLEASE NOTE: If you submit the referral form and do not hear back from us within 1 business day, please email us at referral@shelteredalliance.org

Alliance Referral Form

Date(Required)

MM slash DD slash YYYY

DO NOT put identifying information on this application. Please identify the person for whom this referral is being made with the person’s 3 initials and age, for example: AGW21

First Initial Middle Initial Last Initial

Age(Required)

Please enter a number from 0 to 115.

Referrer

Who is submitting this referral:(Required)

If placed outside of a 3-4 hour drive of location, could you need assistance with transportation?(Required)

Please note this does not guarantee assistance with transportation.

How did you hear about us?

How long have you known this person?(Required)

Number of days, months, years

Contact

This information will be used by Service Providers to reach you --- if you are referring yourself, please DO NOT INCLUDE YOUR NAME.

Name

First Last

Agency/Organization Name

Location(Required)

City State

If you are referring yourself, please DO NOT use an email address that identifies you by name.

Phone

Please use a valid phone number.

Where is the individual seeking services located?

City State

Information to Facilitate Ideal Placement

Gender/Sex(Required)

Female

Male

Transgender (gender identity differs from the sex the person was given at birth)

Non-binary (does not identify as exclusively a man or a woman)

Two-Spirit (masculine and feminine spirit)

Select all that apply

Race / Ethnicity Optional (According to the U.S. Census Bureau)

White (Europe, the Middle East, or North Africa, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, Chaldean, etc.)

Black or African American (Black racial groups of Africa. Such as African American, Jamaican, Haitian, Nigerian, Ethiopian, or Somali, Ghanaian, South African, Barbadian, Kenyan, Liberian, Bahamian, etc.)

American Indian and Alaska Native (North and South America, race as "American Indian or Alaska Native", Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, or Nome Eskimo Community.)

Asian (Far East, Southeast Asia, or the Indian subcontinent. India, China, the Philippine Islands, Japan, Korea, or Vietnam, Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Other Asian, Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.)

Native Hawaiian and Other Pacific Islander (Hawaii, Guam, Samoa, Pacific Islands, Native Hawaiian, Chamorro, Samoan, Other Pacific Islander, Pacific Islander, Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.)

Select all that apply

Are you of Hispanic, Latino, or of Spanish origin? Optional

Are you, or could you be, pregnant?(Required)

How many weeks into pregnancy do you think you are?(Required)

Number of Weeks

Do you need a program that allows you to bring children who are in your custody?(Required)

How many children?(Required)

Number of children

List the age(s) of the child(ren):(Required)

Ex: 3, 6, 7 *Note: some programs may have a limit on the number and/or age of accompanying children.

Preferences

If there is a lack of programs due to preferences, we will contact you directly.

When do you need placement?(Required)

Please select the date you need placement(Required)

MM slash DD slash YYYY

Date

What type of program are you seeking?(Required)

Advocacy/Case Management (No housing)

Short-Term Housing (24 hours up to 3 months)

Long-Term Housing (3+ months)

What sleeping arrangements make you most comfortable (select all that apply)?(Required)

Independent Housing (live alone)

Shared Housing (private bedrooms)

Shared Housing (shared bedrooms)

What level of staff supervision would be most helpful to you?(Required)

Low- could include independent housing and is not at risk of relapse but would benefit from daily or weekly check-ins

Moderate- supervision within the housing situation; some off-campus privileges; some internet/phone use

High- 24/7 supervision with restricted outside communication

No preference

All programs can be assessed on a case-by-case basis, so please select any options you would be comfortable with, or if you are comfortable with all, please select 'No preference.'

Are you comfortable with a program that is religiously affiliated?(Required)

Yes

What type of faith-related program options are you comfortable with?(Required)

Faith-related classes, activities, and/or influences that have mandatory participation

Faith-related classes, activities, and/or influences that have expected attendance, but not mandatory participation

Faith-related classes, activities, and/or influences that are entirely optional

Organization does not provide faith-related classes, activities, and/or influences

No preference

All programs can be assessed on a case-by-case basis, so please select all options you would be comfortable with.

Do you have any preferences or limitation on where in the United States you should be placed? Please explain:(Required)

Limitations could include legal obligations that do not permit you to leave the state.

Do you require services in a particular language? If so, please specify:(Required)

If no specifications, write N/A.

Exploitation Information

What type of exploitation are you seeking recovery from?(Required)

Sex Trafficking

Labor Trafficking

Prostitution

Survival Sex

Other forms of commercial sex

Select all that apply.

How was the trafficking activity verified?(Required)

Individual is a minor; Verification not required

Trafficking was verified by Law Enforcement or Court Official

Individual Disclosure

Candidate met screening criteria for trafficking

Cannot confirm trafficking

If a screening tool was used, please indicate which:

Name of Trafficking Screening Tool

How long ago was your last experience with trafficking or exploitation?(Required)

Please indicate the last time you were exploited (not the first occurrence).

Have you previously (or currently) been in a trafficking shelter program?(Required)

Please list the program(s):(Required)

Legal

Citizenship(Required)

If you're under 18, please specify:

Emancipated

Ward of court/state

About to age out

Parent/Guardian willing to grant temporary custody

Parent/Guardian willing to transfer legal guardianship

Please select all that apply:

I am actively escaping an abuser

I currently have outstanding warrants or legal obligations

I am currently involved in an open or pending investigation(s) or case(s)

I will be on parole or probation

I am part of a diversion program with court requirements

I am currently registered as a sex offender

Are you able to leave the state with the current legal situation(s) checked above?

Are you currently incarcerated?(Required)

What is your anticipated release date?(Required)

MM slash DD slash YYYY

Date

Please describe any outstanding warrants or legal obligations that will affect your ability to travel outside the state:(Required)

If none, write N/A.

Health

I need services that accept the following:(Required)

Immediate health concerns

Physical disabilities

Certified service animal

Emotional support animal

Reported self-injuring

Reported suicide ideation

Diagnosed with a psychiatric/cognitive disorder

Currently taking prescribed medication for mental illness

Experience episodes of psychosis

Used illegal substances in the last 7 days

Used illegal substances in the last 30 days

Use marijuana within a program

Currently taking prescribed medication for opioid treatment

None of the above

Please describe the health concerns:(Required)

Please describe the physical disability and accommodations necessary:(Required)

Please indicate mental health diagnosis(es):(Required)

Please list medications and dosage, if known:(Required)

When was the last time you used addictive and/or illegal substances?(Required)

Have you ever been in rehab for drug or alcohol abuse recovery?(Required)

How many times?(Required)

Are you in need of addiction recovery services?(Required)

Comments

Is there anything else we should know?

In signing below, I (survivor) consent to the release of the information above, OR, I (survivor advocate) verify that I have obtained the consent of the individual for whom this referral is being made to release the information above on their behalf. This information may only be shared with the National Trafficking Sheltered Alliance and their participating network of referral receiving agencies for the express purpose of seeking services.

One or both signatures must be included for NTSA to move forward with the referral. Note: In order to maintain the anonymity of the individual for which this referral is being made, your signature will not be included in the distribution of this information to receiving agencies.

Survivor Signature(Required)

Date

MM slash DD slash YYYY

Date

Survivor Advocate Signature(Required)

Date

MM slash DD slash YYYY

Date

Alliance Referral Form Overview

As you begin...

Alliance Referral Form

Referrer

Contact

Information to Facilitate Ideal Placement

Preferences

Exploitation Information

Legal

Health

Comments

General

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