PTR External Referral Form

Page 1

Page 1: Self-Referrals or Referral Information
Page 2: Client Eligibility
Page 3 (Partner Referrals Only): Client Information

Thank you for your interest in Partnerships for Trauma Recovery!

If you are a referring partner, such as an attorney, community partner, or other client advocate referring a potential client for our services, please provide some information about yourself and your client in order to complete the referral.

If you are a new client looking for services, please select "I am a client" and provide the requested contact information so that PTR staff can contact you for screening.


Please ensure the client's consent to provide demographic information prior to completing this referral
Information of Individual Making a Referral
Please provide your relationship to the prospective client as well as your contact information






Client Self-Referral Information
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.






Begin typing to narrow options and select from the list

Type or use the calendar to enter a date in MM/DD/YYYY format

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed


Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed



PTR's Clinical coordinator will follow up with you to gather more information about your household during your screening call.

Visible for testing purposes only. Please Ignore

Page 2

Page 1: Self-Referrals or Referral Information
Page 2: Client Eligibility
Page 3 (Partner Referrals Only): Client Information

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 
  • Refugees, asylees and asylum-seekers are automatically eligible for our services

A client's immigration status is not a factor in determining eligibility.
Do you meet the PTR eligibility criteria stated above?
Does the client meet the PTR eligibility criteria stated above?
African Communities Program Eligibility Requirements
PTR is also proud to offer wellness support to clients who are of African descent through the African Communities Program
Are you of African descent?
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.

Page 3

Page 1: Self-Referrals or Referral Information
Page 2: Client Eligibility
Page 3 (Partner Referrals Only): Client Information
Client Scheduling Information



If client's date of birth is unknown, please estimate a DOB by entering 1/1/YYYY with a year that would result in the client's approximate age


Client Address

Begin typing a street address and select from the suggested list to populate all address components. County must be provided separately







Language and Interpretation Information

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed




Client Demographic Profile/Immigration Information
Please provide the following demographics for your client as required by our funders. If your client does not wish to provide some of the information requested, please indicate "Chose Not to Respond."

In addition to helping us better understand the communities that we serve, providing complete and accurate information helps our staff to refer clients for other services that may be of benefit to them.

Demographic Information


Begin typing your client's country of origin. Suggested options will generate as you continue typing.

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed

Immigration Information




Use this box as a reference for estimating an arrival date. Years in US will calculate based on the date that you enter above
If client's US arrival date is unknown, please estimate a date by entering 1/1/YYYY with a year that would result in approximate number of years in the US. If a month of arrival is known, estimate a date by entering M/1/YYYY.

Click into the box to see options or begin typing and select from the list. Please select "Chose Not to Respond" if your client does not have a formal immigration status. Immigration status is NOT a factor in overall eligibility for PTR services.



Providing documentation of a client's legal immigration status assists us in determining eligibility for further services and expedites our screening process. Immigration status is NOT a factor in overall eligibility for PTR services, but knowing a client's immigration status ensures we provide your client with the services they need.
Client Household Information

First Additional Household Member Information




If client's date of birth is unknown, please estimate a DOB by entering 1/1/YYYY with a year that would result in the client's approximate age



First Additional Household Member Address

Begin typing a street address and select from the suggested list to populate all address components. Count must be provided separately





First Additional Household Member Contact Information



First Additional Household Member Language and Interpretation Information

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed




First Additional Household Member Demographic Profile/Immigration Information
Please provide the following demographics for your client as required by our funders. If this individual does not wish to provide some of the information requested, please indicate "Chose Not to Respond."

In addition to helping us better understand the communities that we serve, providing complete and accurate information helps our staff to refer clients for other services that may be of benefit to them.

Demographic Information


Begin typing the country of origin. Suggested options will generate as you continue typing.

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed

Immigration Information




Use this box as a reference for estimating an arrival date. Years in US will calculate based on the date that you enter above.
If client's US arrival date is unknown, please estimate a date by entering 1/1/YYYY with a year that would result in approximate number of years in the US. If a month of arrival is known, estimate a date by entering M/1/YYYY.

Click into the box to see options or begin typing and select from the list. Please select "Chose Not to Respond" if your client does not have a formal immigration status. Immigration status is NOT a factor in overall eligibility for PTR services.



Providing documentation of a client's legal immigration status assists us in determining eligibility for further services and expedites our screening process. Immigration status is NOT a factor in overall eligibility for PTR services, but knowing a client's immigration status ensures we provide your client with the services they need.

Second Additional Household Member Information




If client's date of birth is unknown, please estimate a DOB by entering 1/1/YYYY with a year that would result in the client's approximate age



Second Additional Household Member Address

Begin typing a street address and select from the suggested list to populate all address components. Count must be provided separately





Second Additional Household Member Contact Information



Second Additional Household Member Language and Interpretation Information

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed




Second Additional Household Member Demographic Profile/Immigration Information
Please provide the following demographics for your client as required by our funders. If this individual does not wish to provide some of the information requested, please indicate "Chose Not to Respond."

In addition to helping us better understand the communities that we serve, providing complete and accurate information helps our staff to refer clients for other services that may be of benefit to them.

Demographic Information


Begin typing the country of origin. Suggested options will generate as you continue typing.

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed

Immigration Information




Use this box as a reference for estimating an arrival date. Years in US will calculate based on the date that you enter above.
If client's US arrival date is unknown, please estimate a date by entering 1/1/YYYY with a year that would result in approximate number of years in the US. If a month of arrival is known, estimate a date by entering M/1/YYYY.

Click into the box to see options or begin typing and select from the list. Please select "Chose Not to Respond" if your client does not have a formal immigration status. Immigration status is NOT a factor in overall eligibility for PTR services.



Providing documentation of a client's legal immigration status assists us in determining eligibility for further services and expedites our screening process. Immigration status is NOT a factor in overall eligibility for PTR services, but knowing a client's immigration status ensures we provide your client with the services they need.

Third Additional Household Member Information




If client's date of birth is unknown, please estimate a DOB by entering 1/1/YYYY with a year that would result in the client's approximate age



Third Additional Household Member Address

Begin typing a street address and select from the suggested list to populate all address components. Count must be provided separately





Third Additional Household Member Contact Information



Third Additional Household Member Language and Interpretation Information

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed




Third Additional Household Member Demographic Profile/Immigration Information
Please provide the following demographics for your client as required by our funders. If this individual does not wish to provide some of the information requested, please indicate "Chose Not to Respond."

In addition to helping us better understand the communities that we serve, providing complete and accurate information helps our staff to refer clients for other services that may be of benefit to them.

Demographic Information


Begin typing the country of origin. Suggested options will generate as you continue typing.

Click into the box to see options or begin typing and select from the list. Select "Other" in order to provide an option not listed

Immigration Information




Use this box as a reference for estimating an arrival date. Years in US will calculate based on the date that you enter above.
If client's US arrival date is unknown, please estimate a date by entering 1/1/YYYY with a year that would result in approximate number of years in the US. If a month of arrival is known, estimate a date by entering M/1/YYYY.

Click into the box to see options or begin typing and select from the list. Please select "Chose Not to Respond" if your client does not have a formal immigration status. Immigration status is NOT a factor in overall eligibility for PTR services.



Providing documentation of a client's legal immigration status assists us in determining eligibility for further services and expedites our screening process. Immigration status is NOT a factor in overall eligibility for PTR services, but knowing a client's immigration status ensures we provide your client with the services they need.


If you would like to refer any additional members from this client household for services, please provide the names of each additional household member and their relationship to the primary client below.

For family referrals of more than three individuals, PTR's Clinical Coordinator will gather additional information to complete the additional clients' records during their screening call.
Additional Household Member Information



Click "Add another response" above to provide information for another individual.
Reason for Referral

Please note that each individual referred through this form will be placed on the wait list for the PTR program specified in this section.

PTR's Clinical Coordinator will clarify each household member's primary service need during their screening call and can place individual clients on distinct waitlists if needed (ie. One family member is seeking Case Management and another is seeking therapy)

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.

Legal Aid Clinic: Monthly legal consultation clinic, assist with paperwork, targeted referrals.

While more than one service can be provided, please indicate the priority at this time. PTR's Clinical Coordinator can provide additional context around services offered and PTR's wait list process during the screening call. 

You will not be able to submit this form unless eligibility criteria are met. Please contact referrals@traumapartners.org if you have questions.