Foundations 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 AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 Domestic Violence 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 How long have you been working with this client? * Are there any services your client is currently or in the past has utilized at 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 What is your availability to set up a time to discuss your clients fit for our program? * Signature Clear If you are human, leave this field blank. Submit Δ