Foundations Virtual Program Referral Form Thank you for taking the time to refer your client to the Brazen Table virtual program. We look forward to reviewing their application and your referral form. Brazen Table - Foundations Participant Referral Form Date * Agency Name * Contact Name * Email Address * Phone * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Name of Client Being Referred * Check off any circumstances (past or present) experienced by this client: Sex trafficking or exploitation Past Present Labor trafficking or exploitation Past Present Gaps in education Past Present Criminal history Past Present Unstable housing/Homelessness Past Present Loss or lack of employment Past Present Loss or lack of transportation Past Present Poverty Past Present Drug or alcohol abuse Past Present Food insecurity Past Present If this client was involved in trafficking, to your best knowledge, is this client completely out of “the life”? * Yes No N/A What services offered by your organization does this client utilize? * Please verify that your client meets the following criteria: * Over the age of 18 at the start of programming Exhibits high risk factors for trafficking or exploitation, has been trafficked in the past, or has high barriers to employment Has a positive history with referring agency and demonstrates a commitment to personal growth Has an ongoing relationship with a case manager at the referring agency and will continue with services throughout the duration of each phase The ability to commit to once a week virtual check-ins Has reliable internet access and a personal or shared computer (laptop/desktop/tablet) that can be used for the duration of the programming Has access to a device that can record (video and photos) of assignments (ex. phone with camera, digital camera, tablet with webcam) Has access to a kitchen with basic requirements: oven, stove, refrigerator, and sink Capable of communicating in basic spoken and written English Is able to read at a 3rd grade level Has at least a 3rd grade math level Has a desire to learn about basic culinary arts! Client Relationship How long have you been working with this client? In your time with this client, what areas of progress have you seen? * What goals are your client currently working towards with you? * Have you identified any challenges in the client-provider relationship? * How often do you have contact with your client? * Daily Weekly Bi-Weekly Monthly Are you willing and able to attend virtual meetings in order to help your client be successful? * Yes No When is your best availability? Are there any programmatic restrictions that would prohibit or interfere with the client’s ability to participate in scheduled meetings? * Yes No If yes, please specify the restrictions and include times of day your client will not be available. Client Fit Why do you think your client is a good fit for the program? * What are your client’s greatest strengths? * What aspect of the program do you anticipate your client struggling the most in? * What are you hoping for your client to get out of the program? * Signature * Clear If you are human, leave this field blank. Submit
