Samaritan Village Referral Form

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This form is for survivors seeking a Residential placement in a Safe Home. Once you submit this form, we will call you within 24-48 hours. Submissions are monitored daily and answered in the order in which they are received. If there are any issues or concerns with your submission please contact referrals@samaritanvillage.net

Email *

Who is completing this form? *

Survivor in need of placement

Family member/Friend

Referral Agency/Counselor/Advocate/

Other

Required

Referent Name (Person completing referral) *

Referent Phone Number *

Name of Survivor (First and Last) *

Survivor's Age *

Survivor's Email *

Survivor's Phone Number

Survivor's Current Location (City & State)
*

Please indicate the level of urgency for placement.

Less than 1 week

Within 2 weeks

Within 1 month

Clear selection

What type of residential placement is the survivor seeking? WE DO NOT OFFER EMERGENCY PLACEMENT
*

What is the race of the survivor?

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Mixed Race

Required

Does the survivor speak and understand English?
*

YES

Has the survivor ever traded sex for something they needed (safety, food, drugs, a place to stay)?*
*

Yes

Approximately how long was the Survivor trafficked? *

Date the Survivor Exited Trafficking Situation
*

YYYY

Is the Survivor interested in a faith-based program?
*

YES

Does the Survivor have a history of violent or sexual crime offenses?
*

YES

Does the Survivor have any pending legal issues/court hearings in any state?
*

YES

Is the Survivor currently on Probation/Parole *

YES

Has the survivor previously been in a restorative care safe home program? *

Yes

List any programs the survivor has previously participated in and the length of time.

Has the survivor ever received counseling? *

YES

If so, which type of counseling *

ADDICTIONS

BEHAVIORAL/ MENTAL HEALTH

FAMILY

GROUP (IN A PRIOR PROGRAM(S)

TRAUMA

Other:

Required

Please indicate if any of the following apply:

Male

Pregnant

Mother with Child(ren)

LGBTQ+

Blind

Deaf

Wheelchair/Physical Accommodations Needed

Intellectual or Cognitive Disability

Severe Mental Health

Active Eating Disorder

Actively Self Harming

Actively Suicidal/Homicidal

Recent Suicide Ideation/Attempt (within last 30 days)

Incarcerated

Detox Needed

Currently in Detox

Recently released from detox (within the last 30 days)

Currently in need of addiction recovery services

Pet in Care (not a registered service animal)

Registered Service Animal (with supporting documentation)

Recent Mental Health Crisis - Non Hospitalized (within the last 30 days)

Involuntary/Voluntary hospitalization (within the last 30)

None of the above

Other:

Required

Does the Survivor use any nicotine products?

Yes - Cigarettes

Yes - Vapes

Required

Indicate Survivor's mental health diagnoses.

*

Anxiety

Bipolar

Borderline Personality Disorder

PTSD/C-PTSD

Depression

Dissociative Identity Disorder

Schizophrenia

None

Other

Required

Please indicate any type of medication currently being taken by Survivor

Not taking any medications

Stimulants (Adderall, Ritalin, Vyvanse, etc)

Mood Stabilizers (Lithium, Abilify, Saphris, Vraylar, etc)

Antipsychotic (Risperdal, Seroquel, Ziprasidone, etc)

Injectables (insulin, etc)

Anti-Anxiety (Xanax, Klonopin, Valium, Ativan, etc)

Anti-Depressants/SSRI's (Prozac, Seroxat, Lustral, Cipramil, etc)

Methadone

Suboxone

Hormone Therapy (estrogen, testosterone, etc.)

Medical Marijuana

Narcotic (Codeine, Fentanyl, Hydrocodone, Morphine, Tramadol)

Other:

Required

Please list any known medical conditions *

Send me a copy of my responses.

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