Minor Programming Referral Form

Questions? Call the RAHAB Office: 330-819-3326

RAHAB Ministries serves youth survivors of human trafficking and youth at high risk for human trafficking through mentorship and case management services.

Mentoring is available in Summit and Cuyahoga Counties.

Case Management is available throughout Northeast Ohio.

RAHAB Minor Programming Referral Form

Referral Information

Please fill out this form to the best of your ability. RAHAB serves youth survivors of human trafficking, and youth at high-risk of being trafficked. Mentoring services are available in Summit and Cuyahoga Counties. The Willows program is available throughout Northeast Ohio.

Date of Referral(Required)

Referral Source Name(Required)

Referral Source Phone Number(Required)

Referral Source Email(Required)

I understand that RAHAB serves youth survivors of human trafficking or those at high risk of trafficking. Referrals for youth not meeting those criteria will not be considered for services.(Required)

I agree that the youth I am referring is a victim of human trafficking or is at high risk for victimization.

Which service are you referring the youth for?(Required)

1:1 Mentoring

The Willows: Case Management & Family Support (Mentoring included)

Unsure and would like RAHAB staff to assess need.

RAHAB provides 1:1 mentorship for youth and/or wrap-around case management services to youth and their families. You are able to refer youth to either or both of these programs.

If you accepted the Willows program, please agree to participate in a multi-disciplinary team (MDT) meeting monthly for the youth being referred(Required)

I agree

N/A - I did not accept the Willows program.

As the referral source, you will be asked by RAHAB to participate in a multi-disciplinary team (MDT) meeting monthly for the youth being referred.

Immediate needs for the youth(Required)

Other Immediate Needs

Youth Information

Youth Name(Required)

First Last

Preferred Name (If different than legal name)

Preferred pronouns

Gender(Required)

Primary Language(Required)

Sexual Orientation (To the best of your knowledge)(Required)

Race(Required)

Date of Birth(Required)

Youth Phone Number

Youth Email

Name of School, School District, and Grade(Required)

Is there anything RAHAB should be made aware of that is crucial to our service to the youth? (Ie. Mental health conditions, external pressures, etc.)(Required)

What are some of the target areas in the youth's life that we should be encouraging? (Ie. areas they've previously struggled with, graduation, etc.)(Required)

Does the youth have any positive or negative connections/relationships with other youth that we need to be aware of?(Required)

This type of information is useful for keeping youth separated who may know each other.

Are there any known triggers for the youth?(Required)

Please list all locations the youth is NOT permitted to go. (Ie.

Guardian Information

Guardian Name(Required)

First Last

Guardian Email(Required)

Guardian Phone Number(Required)

Guardian Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian has been notified regarding this referral.(Required)

Yes

Is the guardian the primary contact (best way to reach the youth)? If no, please list the name, relationship to the youth and contact information for the point of contact.(Required)

Residential Information

Youth Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the youth currently living at the above address?(Required)

Yes

Who does the child live with? Please include name & relationships.(Required)

Any information on the child's residence we should be aware of? (Parents in denial, encouraging poor behavior, unsafe persons, etc.)

Trafficking & Exploitation History

Why is this youth considered a human trafficking victim or at high risk of trafficking?(Required)

Types of Victimization(Required)

Other types of victimization

Are there any relatives/parents/persons who are suspected of being involved in the trafficking of this youth?(Required)

Any history of AWOL?(Required)

Service Provider Information

What other services does the youth currently have in place? Ie. Counseling, Drug Rehabilitation, Case Management, etc.(Required)

Probation Officer (Name, Phone, & Email)

Case Worker (Name, Agency, Phone, & Email)

GAL (Name, Agency, Phone, & Email)

Additional Contact (Name, Position, Agency, Phone, & Email)

Any Remaining Information

Is there anything else about the youth, the situation, or the referral that RAHAB should know before proceeding?