Human Trafficking Services Referral

Client Demographic Information

Last Name

First Name

Date of Birth

Gender: check all that apply
FemaleMaleTransgenderNon-binaryGender non-conformingOther

Preferred Gender Pronoun

Does client identify as LGBTQ+?
YesNoUnknown

Race: check all that apply
White/CaucasianAfrican American/BlackAsianAmerican Indian or Alaskan NativePacific IslanderOtherUnknown

Language(s) spoken

Country of origin

Client telephone number (if applicable)

Client email (if applicable)

Guardian/Sponsor Information

Name

Phone number

Email

Referral Information

Referred by (name and title)

Agency

Phone number

Email

List any other community agencies client is involved with (i.e. Durham Recovery, Carolina Outreach, etc.)

Upload related documents, if necessary