Intake/Referrals

Seeking Help or Making Referral

Are you seeking help or making a referral?

Seeking Help

Making a Referral

Referring Source Information

Today's Date

Name of Individual Making Referral

First Last

Organization (if applicable)

Phone

Are you the primary contact for this survivor? (i.e. Are you the best individual to field questions relating to this survivor's placement?)

Yes

How long have you known the survivor?

Primary Contact's Name

First Last

Role/Title

Organization

Phone

Survivor Information

Initials of Survivor's Name

Survivor's Age

Survivor's Sex at Birth

State in which survivor is currently located

Survivor's current situation? (homeless, living with family, detained, in another program, etc.)

When does the survivor want placement? I.e. are they in immediate need or are they currently in a safe situation?

Does the survivor speak English?

Yes

Some

Does the survivor speak any other languages? If so, please list.

What is the best way for Onehope Refuge to get in contact with the survivor?

Phone Call

Text

Phone

Is there anything Onehope Refuge should be aware of in terms of contacting the survivor?

Onehope Refuge Eligibility Information

Onehope Refuge is a shelter for women who are exiting sex trafficking situations and have children in their care. These questions serve to confirm the survivor is eligible for our program.

Onehope Refuge is a shelter for women who have children in their care and/or are pregnant. Does the survivor have at least one child in her care and/or is she pregnant?

Yes

Is the woman a survivor of sexual exploitation/sex trafficking?

Yes

Do you need to see specific questions that can help determine whether the survivor experienced sexual exploitation/trafficking?

Yes

**These are some questions you can use to determine sex trafficking**

1. Have you ever had to engage in sex acts for something of value to you such as food, clothing, a place to stay, drugs, medicine, transportation, or money?

2. Are you currently involved in the sex industry such as working in a club, hotel, out of a residence, on the street?

How was the survivor's sexual exploitation/trafficking verified? (law enforcement, self, etc.)

The following questions serve to provide the survivor with information regarding Onehope Refuge and what our program entails to help them decide whether Onehope Refuge could be a good fit for them.

Onehope Refuge is a Christian faith-based organization. Is the survivor willing to enter a program that includes Christian faith-based activities and practices?

Yes

Onehope Refuge is a residential facility. Is the survivor willing to enter a residential facility with their child/ren?

Yes

For safety reasons, our program begins as a cell phone-free program. Is the survivor willing to surrender their cell phone until they progress further into the program? Note that the survivor will still be able to make phone calls to safe individuals from a Onehope Refuge phone.

Yes

To promote an environment of safety and restoration, Onehope Refuge is a substance- and sex- free facility. Is the survivor willing to agree to abstain from drugs, alcohol, and sex throughout their time at Onehope Refuge?

Yes

Onehope Refuge provides case management services to all residents. Is the survivor willing to engage in case management services throughout their time with Onehope Refuge?

Yes

What type of program is the survivor seeking? (Onehope is a long-term transitional care model)

How long is the survivor looking to reside in the shelter? Onehope Refuge is intended to provide support for up to 2-5 years.

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

Independent Housing (live alone)

Shared Housing (private bedrooms)

Shared Housing (shared bedrooms)

What level of staff supervision would be most helpful to you? (Onehope is moderate to high)

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

Moderate – could include 24/7 staff care and engagement with parenting and living

High – 24/7 supervision with restricted outside communication

Share about other trafficking shelters survivor has participated in and the reason for leaving or being dismissed.

Pregnancy Information

Is the survivor pregnant?

Yes

Weeks/months of pregnancy?

Has the survivor seen a doctor regarding this pregnancy?

Yes

No, but appointment is scheduled

No, and no appointment has been scheduled

Date of Appointment

Substance Use Information

Does the survivor have a history of drug use?

Yes

Which drug(s)?

Date/timeframe of last use of drug?

Please describe the survivor's drug usage/journey to getting clean. How much clean time do they have? What efforts have been made (if any) to get clean?

Does the survivor have a history of alcohol use?

Yes

Please describe the survivor's relationship with alcohol. How much? How frequent? How impactful on their life?

When did the survivor last drink alcohol?

Health Information

Please list any mental health diagnosis given by a psychiatrist.

Anxiety and/or Depression

PTSD and/or CPTSD

Psychosis

Bipolar

DID/Multiple Personality or Borderline Personality Disorder

Schizophrenia

Eating Disorders

Please list any mental health diagnoses the survivor has and include who diagnosed them.

Please list ALL medications that the survivor is currently taking. Include both prescription and over-the-counter.

Does the survivor have any disabilities that inhibit functioning?

Yes

Please explain.

Does the survivor have or been diagnosed with a Traumatic Brain Injury?

Yes

Please explain and include any information regarding treatment.

Legal Information

Please describe any legal issues/concerns that the survivor has.

Select all that apply to the survivor:

Active Court Case

Registered Sex Offender

Warrant

Probation/Parole

What state is the active court case in?

What state is the sex offender registration in?

What state is the warrant in and what is the warrant for?

What state is the probation/parole in?

Children Information

Some questions will be not applicable due to age of child/ren. Please use N/A if the below questions do not apply.

How many children does the survivor have (not including any current pregnancy)?

Has Children's Services at the Department of Health and Human Services been involved with the survivor and her child/ren?

Yes

Please explain the involvement of Children's Services.

Does the survivor have legal custody of her child/ren through the court system?

Yes, Survivor has full custody

No, someone else has full custody

Partial/Joint custody

No court involvement

Name of court system that ruled on custody?

Address of court system that ruled on custody?

Child 1

Child's Initials

Child's Age

Child's Sex at Birth

Is child up to date on vaccines?

Yes

Unknown

Date of last doctor's appointment

Is this child's father involved in the care of the child?

Yes

Does the child's father have visitation?

Yes

What are the visitation arrangements (certain days/weekends)?

Is visitation court ordered? If yes, please note that Onehope Refuge will need a copy of the court order if the survivor and her child come to Onehope Refuge.

Yes

Select all that apply:

This child has a medical diagnosis

This child has a mental health diagnosis

This child has a disability that inhibits functioning

This child has a traumatic brain injury

This child has one or more legal issues

This child has a history of alcohol use

This child has a history of drug use

This child is pregnant

Please list all medical diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list all mental health diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list any disabilities the child has that inhibit functioning and list any accommodations they may need.

Please explain the traumatic brain injury and provide any information regarding treatment.

Select any that apply to the child's legal situation:

Active court case

On a sex offender registry

Warrant

Probation/Parole

Please describe any legal issues the child has and list what state they are based in.

Please describe the child's alcohol use, including when alcohol use began, how often the child drinks, how much the child drinks, and how long the child has been clean from alcohol use.

Please describe the child's drug use, including which drug(s) have been used, when drug use began, how often the child uses the drug(s), and how long the child has been clean?

Weeks/Months of Pregnancy?

Has the child seen a doctor regarding this pregnancy?

Yes

No, but appointment is scheduled

No, and no appointment has been scheduled

Date of Appointment

Child 2

Child's Initials

Child's Age

Child's Sex at Birth

Is child up to date on vaccines?

Yes

Unknown

Date of last doctor's appointment

Is this child's father involved in the care of the child?

Yes

Does the child's father have visitation?

Yes

What are the visitation arrangements (certain days/weekends)?

Is visitation court ordered? If yes, please note that Onehope Refuge will need a copy of the court order if the survivor and her child come to Onehope Refuge.

Yes

Select all that apply:

This child has a medical diagnosis

This child has a mental health diagnosis

This child has a disability that inhibits functioning

This child has a traumatic brain injury

This child has one or more legal issues

This child has a history of alcohol use

This child has a history of drug use

This child is pregnant

Please list all medical diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list all mental health diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list any disabilities the child has that inhibit functioning and list any accommodations they may need.

Please explain the traumatic brain injury and provide any information regarding treatment.

Select any that apply to the child's legal situation:

Active court case

On a sex offender registry

Warrant

Probation/Parole

Please describe any legal issues the child has and list what state they are based in.

Please describe the child's alcohol use, including when alcohol use began, how often the child drinks, how much the child drinks, and how long the child has been clean from alcohol use.

Please describe the child's drug use, including which drug(s) have been used, when drug use began, how often the child uses the drug(s), and how long the child has been clean?

Weeks/Months of Pregnancy?

Has the child seen a doctor regarding this pregnancy?

Yes

No, but appointment is scheduled

No, and no appointment has been scheduled

Date of Appointment

Child 3

Child's Initials

Child's Age

Child's Sex at Birth

Is child up to date on vaccines?

Yes

Unknown

Date of last doctor's appointment

Is this child's father involved in the care of the child?

Yes

Does the child's father have visitation?

Yes

Is visitation court ordered? If yes, please note that Onehope Refuge will need a copy of the court order if the survivor and her child come to Onehope Refuge.

Yes

Select all that apply:

This child has a medical diagnosis

This child has a mental health diagnosis

This child has a disability that inhibits functioning

This child has a traumatic brain injury

This child has one or more legal issues

This child has a history of alcohol use

This child has a history of drug use

This child is pregnant

Please list all medical diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list all mental health diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list any disabilities the child has that inhibit functioning and list any accommodations they may need.

Please explain the traumatic brain injury and provide any information regarding treatment.

Select any that apply to the child's legal situation:

Active court case

On a sex offender registry

Warrant

Probation/Parole

Please describe any legal issues the child has and list what state they are based in.

Please describe the child's alcohol use, including when alcohol use began, how often the child drinks, how much the child drinks, and how long the child has been clean from alcohol use.

Please describe the child's drug use, including which drug(s) have been used, when drug use began, how often the child uses the drug(s), and how long the child has been clean?

Weeks/Months of Pregnancy?

Has the child seen a doctor regarding this pregnancy?

Yes

No, but appointment is scheduled

No, and no appointment has been scheduled

Date of Appointment

Child 4

Child's Initials

Child's Age

Child's Sex at Birth

Is child up to date on vaccines?

Yes

Unknown

Date of last doctor's appointment

Is this child's father involved in the care of the child?

Yes

Does the child's father have visitation?

Yes

Is visitation court ordered? If yes, please note that Onehope Refuge will need a copy of the court order if the survivor and her child come to Onehope Refuge.

Yes

Select all that apply:

This child has a medical diagnosis

This child has a mental health diagnosis

This child has a disability that inhibits functioning

This child has a traumatic brain injury

This child has one or more legal issues

This child has a history of alcohol use

This child has a history of drug use

This child is pregnant

Please list all medical diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list all mental health diagnoses for this child, including the doctor/agency that diagnosed the child and any medications the child takes for the diagnosed condition.

Please list any disabilities the child has that inhibit functioning and list any accommodations they may need.

Please explain the traumatic brain injury and provide any information regarding treatment.

Select any that apply to the child's legal situation:

Active court case

On a sex offender registry

Warrant

Probation/Parole

Please describe any legal issues the child has and list what state they are based in.

Please describe the child's alcohol use, including when alcohol use began, how often the child drinks, how much the child drinks, and how long the child has been clean from alcohol use.

Please describe the child's drug use, including which drug(s) have been used, when drug use began, how often the child uses the drug(s), and how long the child has been clean?

Weeks/Months of Pregnancy?

Has the child seen a doctor regarding this pregnancy?

Yes

No, but appointment is scheduled

No, and no appointment has been scheduled

Date of Appointment

Submission

If there is any additional information about the survivor and/or her situation that you have that you would like to share, please do so here.

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Intake/Referrals