Partnerships for Trauma Recovery (PTR) Referral Form

Thank you for your interest in Partnerships for Trauma Recovery!

Information of Individual Making a Referral

Please provide your relationship to the prospective client as well as your contact information

Are you a prospective client or a service provider?

Thank you for your interest in PTR. Please provide your name, contact information & preferred language and someone will be in touch with you within 3 business days.

Your First Name

Your Last Name

Your Organization

Your Relationship to the Client being Referred

Your Email

Your Phone Number

Your First Name

Your Last Name

Primary Spoken Language

Please specify other language

Your Phone Number

Your Email

If you would like to provide further context surrounding your/your client's situation, please do so here:

Details

Your Date of Birth

Your City of Residence

Eligibility for PTR Services

In order to qualify for PTR services, clients must:

Have fled their country of origin due to interpersonal violence (including domestic violence), danger, or persecution OR
Asylees and asylum-seekers are automatically eligible for our services

A client's immigration status is not a factor in determining eligibility.

Does the client meet the PTR eligibility criteria stated above?

African Communities Program

PTR is also proud to offer wellness support to clients who are of African descent through the African Communities Program

Is the client of African descent?

Client does not meet eligibility criteria

Unfortunately, due to limited capacity, we are unable to receive referrals for clients who do not meet our eligibility criteria. Thank you for your understanding. If you have any questions or concerns about our eligibility criteria or would like to consult about a potential referral, please email us at referrals@traumapartners.org. Thank you.

Unknown if client meets eligibility criteria

Before making a referral to Partnerships for Trauma Recovery, please ensure that the client meets our stated eligibility criteria.

If you have any questions or concerns about our eligibility criteria or would like to consult about a potential referral, please email us at referrals@traumapartners.org. Thank you.

Referral Information

Client's First Name(s)

Client's Last Name(s)

Has the client verbally consented to this referral?

Please ensure the client's consent prior to completing this referral

Client Contact Information

Street

Please provide street name and number as well as unit number, if applicable

City

Other City

Please type if the client's city of residence is not listed

State

Zip Code

Please provide the best phone number and email address for contacting the client as well as one alternate phone number

Client Phone

Client Alternate Number

Client Email Address

Client Demographic Information

Please provide the client's demographic information

Gender

Other Gender Explanation

Country of Origin

Date of Birth

If client's date of birth is unknown, please enter 1/1/1980

Is the client's date of birth estimated?

YesNoSelect "yes" if the client's date of birth is unknown

Estimated Age

Language and Immigration Information

Primary Spoken Language

Please specify other language

Does client speak any additional language?

Additional Spoken Language

Please specify other additional language

Level of English Language Ability

Must psychosocial care be provided in a language other than English?

If an interpreter is needed, in which preferred language should interpretation be provided?

Please specify other language for interpretation

Client's Immigration Status

If the immigration status is unknown, please choose 'Other' and enter "Unknown"

Other Status Explanation

Place of Arrival in the United States

If place of arrival is unknown, please enter "unknown"

Date of Arrival in the United States

If client's date of arrival is unknown, please enter 1/1/1980

Reason for Referral

Services offered at PTR:

Therapy/counseling: Individual, family or group counseling to support healing and emotional well-being. Modality will be determined upon assessment and in collaboration with the client.

Case management: Individualized & short-term case management services to assess, make referrals & provide support/advocacy related to concrete needs.

What is the primary service being sought by the client?

While more than one service can be provided, please indicate the client's priority at this time.