Housing Referral Form

1. Please DO NOT make this referral if client is unaware of referral and if she is unaware of the specific services that GEMS provides.
2. Please complete entire referral form in print/type. Attach additional paper if needed. Please fax or mail the completed referral to GEMS, Attn: Aditee Majumdar, Residential Director.  You will be notified if referral is accepted or not. Staff will contact you regarding next steps and/or initial appointments.
3. In addition to answering ALL sections below please attach the following to this referral:

• • Proof of negative PPD test within last 6 months
  • Completed mental health evaluations/psychosocial reports
  • A short written statement by the client as to why they feel that the GEMS program is appropriate for them and what they hope to accomplish/achieve while in the program.

1. Referring Agency(required)
2. Telephone(required)
3. Referring Worker(required)
4. Fax(required)
5. Client Name(required)
6. Date of Birth(required)
7. Age(required)
8. Address(required)
9. Living Arrangements Pimp Family Member Friends Alone Facility Other (required)
10. If other, please explain
11. Client Phone(required)
12. Client Alternate Phone(required)
13. Emergency Contact
14. Relationship to Client
15. Emergency Contact Phone
16. Housing program being referred to Imani Transitional Independent Living Program (required)
17. Does the client have children? Yes No (required)
18. Are you trying to arrange client to be mandated to GEMS? Yes No (required)
19. Has the client been sexually exploited? Yes No (required)
20. If so, what form(s) of sexual exploitation? Prostitution Stripping Escort Service Phone Sex VIP Trading sex for money, drugs, gifts or survival needs
21. Has the client been involved in any type of abusive relationship? Yes No (required)
22. If so, what form(s) Physical Abuse Sexual Abuse Emotional Abuse Verbal Abuse Rape Molestation
23. Why do you think this young woman would be appropriate for GEMS' services?(required)
24. Does the client have: State ID Birth Certificate Social Security Card Medical Insurance (required)
25. If your client has medical insurance, what kind does she have??
26. Additional Information