Make a Referral For Georgia and Tennessee, we serve as a statewide coordinating agency connecting services and treatment care for individuals.If you know a child or adult who is at risk, please refer them to us using one of the forms below. YOUTH REFERRAL FORM ADULT REFERRAL FORM Youth Referral Form Name of the person completing referral * First Name Last Name Phone * (###) ### #### Email * Please check what type of agency/provider you are affiliated with: Parents independent Court Community Medical Mental Health School Law Enforcement Division of Family & Children Services (DFCS) Department of Juvenile Justice (DJJ) Is the physical custodian of the youth requesting an assessment within 24 hours of submitting the completed referral? Yes No Unknown Please indicate any scheduling preferences (preferred day / time). * Youth Referral Information Youth Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female Other Ethnicity * Is client currently pregnant? * Yes No Is client actively parenting? * Yes No Languages Spoken: * Does youth have a disability? * Yes No Who has custody of youth? * Parents Father Mother DFCS DJJ/Court Other Family Relative Other Youth Address and Location Listed/Legal Address * Address 1 Address 2 City State/Province Zip/Postal Code Country County * Current Location County Is this a safe location? * Yes No Legal Guardian Name of Legal Guardian * First Name Last Name Phone * (###) ### #### If youth does not reside with legal guardian, provide the name and phone number for current placement: Name First Name Last Name Phone (###) ### #### Reason for Referral What is the reason for your referral for sexually exploited/trafficked youth services? * Please provide details. Prior history of exploitation: * Please check all that apply * Human Trafficking Labor Trafficking At Risk (i.e mental health, homelessness, past trauma etc) Runaway history Firearm/weapon use Giving false name Gang involvement Homelessness Loitering for solicitation Substance abuse Online ads for solicitation History of childhood sexual abuse Law Enforcement involvement case Family history in sexual exploitation/trafficking Youth disclosure of sex trafficking/exploitation Youth Information Family/Household Information: (in-home abuse or neglect, family functioning, other siblings, etc.) * Medical History: (pregnancies, STDs/STIs, chronic health conditions, recent medical exams, etc.) * Mental Health Involvement: (substance abuse history, mental health diagnosis, current therapeutic provider, etc.) * Juvenile Justice Involvement: (if no, put N/A. If yes, please include a name or contact, and list any active warrants or charges, if applicable, etc.) * Child Welfare Development: (please provide contact information for Case Manager) * Prior to completing this referral, did you utilize the Georgia Statewide Screening Tool? * Yes No CONSENT FORM AND OBTAIN/RELEASE OF INFORMATION Youth Name * First Name Last Name Youth Date of Birth * MM DD YYYY SECTION A: CONSENT TO SERVICES I authorize the complete release of my records. By signing this form, I consent to receive the following services from Street Grace: comprehensive assessment; care coordination; and follow-up services after discharge. I understand that by signing this form that I am consenting for the youth identified above to participate in Street Grace’s treatment services. SECTION B: USE AND DISCLOSURE OF INFORMATION By signing this form, I authorize the disclosure of my individually identifiable information. Information that may be used or disclosed based on this authorization is as follows: -Information pertaining to the identity, diagnosis, prognosis or treatment for alcohol or drug abuse, mental health disorders, educational issues/needs, legal issues/needs and/or social/recreational issues/needs. -Information concerning the testing for HIV (Human Immune Virus) and /or treatment for AIDS (Acquired Immune Deficiency Syndrome) and any related conditions. -Privileged communications between a psychiatrist, psychologist, licensed marriage & family counselor, or licensed professional counselor or between them concerning communications with them. -All education information; including education records created or received by the school system. This information may include, if applicable: report cards, attendance, discipline, IEP, 504 plan, evaluations. I authorize the disclosure of my complete records and identifiable information by the following and to the following parties: Department of Juvenile Justice, Department of Family and Children Services, Educational Provider, Juvenile Court, District Attorney’s Office, Law Enforcement, Mental Health Providers, Medical Providers, and any other providers as deemed necessary. I authorize for Street Grace to take a photograph of the above mentioned youth, to be shared by the following and to the following parties: Department of Juvenile Justice, Department of Family and Children Services, Educational Provider, Juvenile Court, District Attorney’s Office, Law Enforcement, Mental Health Providers, Medical Providers, National Center for Missing and Exploited Children (NCMEC) and any other providers as deemed necessary. Checkbox * I authorize the release of the complete records except for the following information or to the following party: SECTION C: PURPOSE OF USE OR DISCLOSURE The purpose of this disclosure is for Assessment Program services, Care Coordination Program services, possible completion of Victim’s Compensation application, and possible completion of a NCMEC application and other needed uses. SECTION D: EXPIRATION Consent for Release of Information expires 24 months from the date it was signed. Consent for Information must last no longer than reasonably necessary to serve the purpose for which consent is given (42 CFR 2.31 (a) (9)). By checking this box, I authorize the following expiration event or date that when it occurs, will prohibit Street Grace from giving or receiving information as described above 1. I understand that Street Grace cannot guarantee that the recipient will not disclose this information to a third party. The recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a youth in an alcohol or drug abuse program, the recipient is prohibited under federal law from making any further disclosure of such information unless further disclosure is expressly permitted by written consent of the consumer or as otherwise permitted by federal law governing confidentiality of alcohol and drug abuse patient records (42 CFR, Part 2). 2. I understand that I may refuse to sign this Authorization and that my refusal to sign may affect my ability to obtain services through Street Grace. 3. I understand that I may revoke this authorization in writing at any time, except that the revocation will not have any effect on any action taken by Street Grace in reliance on this authorization before written notice of revocation is received. 4. I understand that educational records are confidential under state and federal law and by signing this Unified Release of Information; I am authorizing the release of educational records. 5. I understand that the data collected from the assessment measures may be used for agency program evaluation efforts. All data shared or published is de-identified to maintain client confidentiality. Signature of Youth Date MM DD YYYY Name of Parent/Legal Guardian: Date MM DD YYYY Signature of Parent/Legal Guardian: Print name of the person completing referral: * Text Signature of the person completing referral: * Thank you for submitting this referral. Adult Referral Form Name of the person completing referral * First Name Last Name Phone * (###) ### #### Email * Please check what type of agency/provider you are affiliated with: Parents independent Court Community Medical Mental Health School Law Enforcement Please indicate any scheduling preferences (preferred day / time). * Adult Referral Information Adult Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female Other Ethnicity * Is client currently pregnant? * Yes No Is client actively parenting? * Yes No Languages Spoken: * Does client have a disability? * Yes No Adult Address and Location Listed/Legal Address * Address 1 Address 2 City State/Province Zip/Postal Code Country County * Current Location County Is this a safe location? * Yes No Reason for Referral What is the reason for your referral for sexually exploited/trafficked services? * Please provide details. Prior history of exploitation: * Please check all that apply * Human Trafficking Labor Trafficking At Risk (i.e mental health, homelessness, past trauma, etc.) Runaway history Firearm/weapon use Giving false name Gang involvement Homelessness Loitering for solicitation Substance abuse Online ads for solicitation History of childhood sexual abuse Law Enforcement involvement case Family history in sexual exploitation/trafficking Disclosure of sex trafficking/exploitation Adult Information Family/Household Information: (in-home abuse or neglect, family functioning, other siblings, etc.) * Medical History: (pregnancies, STDs/STIs, chronic health conditions, recent medical exams, etc.) * Mental Health Involvement: (substance abuse history, mental health diagnosis, current therapeutic provider, etc.) * Criminal Justice Involvement: (if no, put N/A. If yes, please include a name or contact, and list any active warrants or charges, if applicable, etc.) * CONSENT FORM AND OBTAIN/RELEASE OF INFORMATION Adult Name * First Name Last Name Adult Date of Birth * MM DD YYYY SECTION A: CONSENT TO SERVICES I authorize the complete release of my records. By signing this form, I consent to receive the following services from Street Grace: comprehensive assessment; care coordination; and follow-up services after discharge. I understand that by signing this form that I am consenting for the adult identified above to participate in Street Grace’s treatment services. SECTION B: USE AND DISCLOSURE OF INFORMATION By signing this form, I authorize the disclosure of my individually identifiable information. Information that may be used or disclosed based on this authorization is as follows: -Information pertaining to the identity, diagnosis, prognosis or treatment for alcohol or drug abuse, mental health disorders, educational issues/needs, legal issues/needs and/or social/recreational issues/needs. -Information concerning the testing for HIV (Human Immune Virus) and /or treatment for AIDS (Acquired Immune Deficiency Syndrome) and any related conditions. -Privileged communications between a psychiatrist, psychologist, licensed marriage & family counselor, or licensed professional counselor or between them concerning communications with them. -All education information; including education records created or received by the school system. This information may include, if applicable: report cards, attendance, discipline, IEP, 504 plan, evaluations. I authorize the disclosure of my complete records and identifiable information by the following and to the following parties: Department of Corrections, Department of Family and Children Services, Educational Provider, Court, District Attorney’s Office, Law Enforcement, Mental Health Providers, Medical Providers, and any other providers as deemed necessary. I authorize for Street Grace to take a photograph of the above-mentioned adult, to be shared by the following and to the following parties: Department of Corrections, Department of Family and Children Services, Educational Provider, Court, District Attorney’s Office, Law Enforcement, Mental Health Providers, Medical Providers, National Center for Missing and Exploited Children (NCMEC) and any other providers as deemed necessary. Checkbox * I authorize the release of the complete records except for the following information or to the following party: SECTION C: PURPOSE OF USE OR DISCLOSURE The purpose of this disclosure is for Assessment Program services, Care Coordination Program services, possible completion of Victim’s Compensation application, and possible completion of a NCMEC application and other needed uses. SECTION D: EXPIRATION Consent for Release of Information expires 24 months from the date it was signed. Consent for Information must last no longer than reasonably necessary to serve the purpose for which consent is given (42 CFR 2.31 (a) (9)). By checking this box, I authorize the following expiration event or date that when it occurs, will prohibit Street Grace from giving or receiving information as described above 1. I understand that Street Grace cannot guarantee that the recipient will not disclose this information to a third party. The recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a youth in an alcohol or drug abuse program, the recipient is prohibited under federal law from making any further disclosure of such information unless further disclosure is expressly permitted by written consent of the consumer or as otherwise permitted by federal law governing confidentiality of alcohol and drug abuse patient records (42 CFR, Part 2). 2. I understand that I may refuse to sign this Authorization and that my refusal to sign may affect my ability to obtain services through Street Grace. 3. I understand that I may revoke this authorization in writing at any time, except that the revocation will not have any effect on any action taken by Street Grace in reliance on this authorization before written notice of revocation is received. 4. I understand that educational records are confidential under state and federal law and by signing this Unified Release of Information; I am authorizing the release of educational records. 5. I understand that the data collected from the assessment measures may be used for agency program evaluation efforts. All data shared or published is de-identified to maintain client confidentiality. Signature of Adult Date MM DD YYYY Print name of the person completing referral: * Signature of the person completing referral: * Thank you for submitting this referral.
