Phoenix Project - Referral Form
Complete the below referral form. After submission, Foundling staff will be in touch about next steps.
Note: Items with an asterisk (*) are required; all other fields can be left blank if information is unknown.
Referral Source Information (Required)
Referral Source Name
*
First
Last
Referral Source Phone
*
Referral Source Email
*
Referral Source Agency
*
Non-Foundling Agency
The New York Foundling
Name of Referral Source Agency
Foundling Program
Foundling Primary IP
Start Date
MM slash DD slash YYYY
Anticipated End Date
MM slash DD slash YYYY
Client Information (Required)
Client Name
*
First
Last
Client Phone
Client Email
Any Known Special Instructions / Preferences for Contact?
*
Yes
No
If Yes, Explain:
Client Age
*
Please enter a number from
12
to
21
.
Client Date of Birth
*
MM slash DD slash YYYY
Client Primary Language
*
Legal Guardian's Name
First
Last
Legal Guardian's Relation to Client
Legal Guardian's Phone
Legal Guardian's Email
Legal Guardian's Primary Language
Reason for Referral
*
Why do you think this youth would be appropriate for The Phoenix Project?
Are there any immediate needs/safety concerns (suicidal ideation, homelessness, etc)?
*
Yes
No
Unknown
If Yes, Explain:
Does the client know about this referral?
*
Yes
No
If Yes, Explain Response:
Additional Information (Optional)
Has the youth been sexually exploited?
Yes
No
Unknown
If yes, what form(s) of sexual exploitation? Select all that apply:
Sexual act in return for fee, other items, or survival needs
Stripping
Escort Service
Child abuse involving images
Arrested for “prostitution offense”
Other
Does the youth have a history of any of the following?
Running away from home
Sexually transmitted infections or abortions
Substance abuse
Is the youth involved with an older partner?
Yes
No
Unknown
Has the youth experienced intimate partner violence (physical, sexual, or emotional)?
Yes
No
Unknown
What are the youth's living arrangements?
Family Member
Alone
Friends
Trafficker/Pimp
Facility
Unknown
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Does the youth have health insurance (not necessary for referral)?
Yes
No
Unknown
Insurance Provider
Insurance ID
Does the youth have a known emergency contact?
Yes
No
Unknown
Emergency Contact Name
First
Last
Emergency Contact's Relation to Client
Emergency Contact's Phone
Emergency Contact's Email
Emergency Contact's Primary Language
Additional Comments / Questions
Additional Documents
Drop files here or
Select files
Max. file size: 32 MB.
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