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Community Partner Referral Form

Thank you for considering referring a teenage survivor of sexual abuse to Teens With Trauma. Please complete the form below.

Referral Source Information

Client Information

Age
Okay to Contact Guardian?
Yes
No
Race/Ethnicity
Has the survivor expressed interest in participating in therapy?
Yes
No

Insurance

While our services are provided at no cost to survivors, we do need to collect information about the percentage of survivors who have insurance coverage. This information is required for reporting purposes to help us ensure we continue to meet the needs of those we serve and maintain the necessary funding for our programs.

Does the survivor have insurance?
Yes
No
Unsure

Confidentiality Statement

We assure you that all provided information will be treated with utmost confidentiality and in compliance with legal and ethical guidelines. It will only be shared with our intake coordinator and therapy team members involved in care. This referral does not guarantee care.


Thank you for providing the necessary information to support the survivor's journey toward healing and recovery. Please submit this completed form and notify the guardian or client that our intake coordinator will be in contact with them.


If you have any questions or need further assistance please email us at support@teenswithtrauma.com or call or text us at 443-377-3021.

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