Referral Application

Referring a Survivor

"Hope is an everyday thing now! I have a network of people that I can reach out to I need to. Together with the assistance of my caseworkers and mentors. I have built a solid foundation for myself that won't easily crumble."
- Priceless Survivor

Referring a Survivor for the Priceless Program

Prior to submitting a referral please confirm the survivor is interested in being a part of the Priceless mentorship program.

Criteria for evaluation of acceptance into Priceless includes:

Trafficking Background - Must have been trafficked within the last 5 years of application date.
Mentorship Participation - Must agree to being mentored by Priceless mentor team. Priceless is a mentorship program, not a social services provider.
Safety Evaluation - Applicant must not pose a credible risk to the safety of Priceless, mentors or volunteer. Aspects of consideration will include criminal history and active cases, known assaults of altercations with other agencies or individuals.
Alcohol and Substance Abuse - Applicant will not be denied services based on existing alcohol or substance abuse. However, entrance into a treatment program is required for such an applicant in order to patriciate in Priceless. Treatment must started before mentors are assigned to the client.
Physical and Mental Health Evaluation - Applicant will not be discriminated against based upon physical or mental health conditions. However, Priceless is a mentorship program and is not equipped to directly provide any form of physical or mental health services. If the applicant requires a level of care that Priceless determines is beyond our program abilities to serve that applicant through mentorship and resource connection, Priceless reserves the right to refer the applicant to another appropriate organization or resource.

Referring Agency/ Contact Information

* Indicates required field

Referring Agency *

Referred By *

First

Last

Email *

Phone Number *

Survivors Name *

First

Last

Do you know of other organizations or agencies previously or currently providing services to the applicant? *

Yes No

If yes, please provide service information. *

If the applicant has worked directly with you or your staff, have there been any safety, behavioral, or verbal altercations in the last 30 days? Prior to that? *

Yes No

If so, please provide more details about the altercation. *

Do you know of any reasons Priceless staff and volunteers may be at risk for safety when interacting with applicant? (Recent assaults, red flags, mental health concerns, drug or alcohol abuse, etc.) *

Yes No

If so, please explain in detail. *

How long was the survivor in your program? If not in a program, how long have you known them? *

What services are you providing? *

Is there anything else we should know in evaluating this applicant? *

Do you have an active Release of Information (ROI) on the applicant we can use? *

Yes No

Attach ROI *

Max file size: 20MB

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Referring a Survivor

Referring a Survivor for the Priceless Program

Referring Agency/ Contact Information

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