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 * Contact Title * 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 Lack of child care Past Present If this client was involved in sex trafficking, to your best knowledge, does this client maintain ties to anyone they know/knew in "the life?" * Yes No N/A What services offered by your organization does this client utilize? * Are there any services your client could utilize that are not provided by your agency? * 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 Proficiency in spoken and written English communication Proficient in reading comprehension at a 3rd grade level or higher Proficient in math at a 3rd grade level or higher Has a desire to learn about basic culinary arts and food service/hospitality 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
