The Net's Enrichment Program Referral Form

The Net's Enrichment Program Referral Form
Please know that The Net is resourced to provide services for a participant who meets the following criteria:
- Women over the age of 18 at the time of applying
- Has been clean and sober at least 30 days (at the time of intake)
- Free from imminent threat from others
- Not a threat to herself or others
If all of the above are true of the applicant, we look forward to learning more through this application.

This form assists The Net staff in determining whether we are the best fit for an applicant to participate in our Enrichment program. We ask that all information be completed in a concise, thorough manner. The application will be reviewed by the multi-disciplinary team before making any determination of an intake being conducted.

Completion of this application assumes the participant consents to allow the Referring Agency/person to provide this information in consideration for her participation at The Net. We do not discriminate based on the responses provided on this form. Your candid, factual, and complete responses assist us in proceeding with the referral process.
Female is over the age of 18
Female has been clean and sober at least 30 days
Female is free from imminent threat from others
Female is not a threat to herself or others
Female is suspected to have been sexually exploited and/or trafficked.
Survivor's Name

First NameLast Name
Survivor's Date of Birth

MonthDayYear
Date
Survivor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is this a safe number for us to contact the survivor?
Survivor's Email
Does the survivor reside in Tarrant County?
Name of person completing application:

First NameLast Name
Relationship to Survivor
Name of Referring Agency (if applicable)
Agency Contact Email
Brief description of reason for the referral.
Should be Empty: