Safe Shelter Referral formPlease complete the form below to refer a family or individual to Safe Shelter. We will follow up as soon as possible. Name of Referrer * First Name Last Name Referral Organization Referral Email * Referral Phone # * (###) ### #### Referred Individual/Families Initials Where is the individual or family you are referring currently staying (i.e. other shelter, car, couch surfing, etc.)? * Is this referral for a family with children under 18? * Family with kids (under 18) Individual If yes, please give age of children, gender and other deomographic info Has the family or individual you are referring experienced discrimination or harassment due to race, gender/sexual identity, etc (i.e. racial slurs, transphobia)? * Yes No I'm not sure Is the individual or family you are referring is actively fleeing intimate partner violence or human trafficking? * Yes No I am not sure What are the specific barriers that have kept your referral from accessing shelter elsewhere (i.e. racism, gender identity discrimination, pet, etc.) Thank you! We have received your referral and will be in touch soon.
