Referrer Info
Date of referral
Referring Person's Name
Agency
Best Mode for Follow up
Phone
Email
You may check both
Ref. Phone
Ref. Email Address
Ref. Phone
Ref. Email Address
Ref. Phone
Ref Email Address
Best Days/Times to follow up
--------------------------------------------------
-
--------------------------------------------------------------------------------------------------------------------
Client Information
First Name
Last Name
Preferred/Other Name
Date of Birth
mm/dd/yyyy format. If you do not know the client's DOB, you can enter 01/01/1900
--------------------------------------------------
-
--------------------------------------------------------------------------------------------------------------
Preferred method of contact
Email
Text
Phone call
Whatsapp
Other
Email address
Email Address safe to use?
Yes
No
Phone number
Phone safe to use?
Yes
No
Safe to leave voice message?
Yes
No
Safe to text?
Yes
No
Whatsapp Name
Other type
Other user name (if applicable)
--------------------------------------------------
-
--------------------------------------------------------------------------------------------------------------
Street Address
City
State
Zip Code
Borough
Please select...
Manhattan
Brooklyn
Queens
Bronx
Staten Island
Out of City
Languages Spoken
Please select...
English
Spanish
French
Mandarin
Albanian
American Sign Language
Amharic
Anaang
Arabic
Armenian
Bambara
Bengali
Bulgarian
Burmese
Cantonese
Creole-Dominican
Creole-Haitian
Creole-St. Lucian
Croatian
Czech
Dari
Don't Know
Don't Wish to Answer
Dutch
Fanti
Farsi
Filipino
Finnish
Fula
Fulani
Fuzhou
Garifuna
Georgian
German
Greek
Gujarati
Gwi
Haya
Hebrew
Hindi
Hungarian
Idoma
Igbo
Indonesian
Italian
Japanese
Javanese
Kannada
Kasem
Korean
Luganda
Malay
Malinke
Mandingo
Mandinka
Manjago
Marathi
Mixtec
Montenegrin
Nepali
Other
Pashto
Polish
Portuguese
Pulaar
Punjabi
Quechua
Romanian
Russian
Serbian
Shona
Sinhala
Slovakian
Soninke
Sou Sou
Swahili
Swedish
Sylheti
Tagalog
Taisonese
Taiwanese
Tamil
Telugu
Thai
Tibetan
Tigrinya
Tiv
Tlapaneco
Toubbou
Turkish
Twi
Ukrainian
Urdu
Uzbek
Vietnamese
Wolof
Wu
Yemba
Yiddish
Yoruba
Insurance Status
No insurance
Has insurance
Eligible for Medicaid but not enrolled
Not sure
We provide services for all clients, regardless of insurance. If you are unsure if the client has insurance, choose "Not Sure"
Type of Insurance
Gender Identity
Female/Girl/Woman
Male/Boy/Man
Genderqueer/Nonbinary
Questioning
Other
Prefers not to disclose
Unknown
Gender Pronouns
She/Her
He/Him
They/Them
Not listed
Other
Does the client identify as trans*?
-------------------------------------------------
-
--------------------------------------------------------------------------------------------------------------------
Reason for needing trauma-informed care
Sex Trafficking (ST) or Commercial Sexual Exploitation (CSE)
Experiences in the commercial sex trade
Childhood sexual abuse
Adult sexual violence
Female genital cutting/mutilation
Intimate partner sexual violence
Other forms of sexual or gender based violence
Please be advised: We provide legal, medical, and social services to survivors of ST, CSE, and people with experiences in the sex trade. For survivors of other forms of sexual violence, we are only able to provide oby/gyn services.
Services being sought
OB/GYN
Services being sought
Medical
Needs affiadavit for asylum/other reasons
Mental health
Legal
Case management
Economic empowerment
Referrals
"Ending the Game" Groups
Caregiver Workshops
Thriving Groups
Other
Medical services being sought
Primary care
OB/GYN
Other Medical Service
Please note: we no longer provide psychiatry services as part of our mental health services.
Which of the following service providers does the client already have?
Gynecologist
Primary care physician
Therapist/Counselor
Psychiatrist
Case manager
Other
Others
Were the services:
Requested by client
Suggested to client
Mandated
Any additional information, concerns, or requests
Has client been informed that EMPOWER staff will reach out?
Yes
No
If you have not informed the client, please do so client is aware that staff will be contacting them
Please send release and any other supporting documents to empower@sffny.org. Please include the date of the referral and the name of the client being referred.
services being sought text
Contact Information