Date

This referrals is being provided by:*

Is it safe for Daughters of Worth to contact the survivor?

Survivor's Date of Birth*

Does the survivor meet the criteria for identification as a trafficking victim? (Being compelled by the use of force, fraud, or coercion to conduct commercial sex acts?)*

Is the survivor supportive of this referral, desiring assistance?*

Is the survivor currently safe?*

Does the survivor have children?*

If the survivor has children, are they in her custody?*

Is the survivor in need of detox or inpatient services for substance use disorder?*

If relocation services are needed, is the survivor willing to relocate out of state?*