Please complete the referral form below to apply for assistance. Name of Legal Guardian (required) Relation to Child (required) Your Email Address (required) Your Phone Number (required) Address (required) Child's Legal Name (required) Nickname if Preferred Child's Age (required) Child's Birthday (required) Siblings? Ages? Special Needs? YESNO Accommodations Needed? YESNO Tribe Affiliation? If so, which tribe? Perpetrator Incarcerated? YESNO Arrest Date Arrest Location Case Filed? YESNO Case Number County? Additional Case Details Is there an imminent threat to the child? YESNO Safety Concerns? Is child welfare involved? CPSDHSICWNONE If so, which county? Is child in counseling? YESNO [recaptcha]
