SARAC Referral Form

Referral Date*

County of Referral*

Client Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone

Ages of children in the house (select all that apply)

0-6
7-12
13-17

Number of children age 0-6*

Number of children age 7-12*

Number of children age 13-17*

Reason for Referral*

Transportation
Food Insecurity
Behavioral Health Resources
Utility Assistance
Clothing Needs
Substance Use Resources
Other

If other, please explain*

Referring Partner*

Name of Person Referring*

First Last

Email*

Phone*

Partnership Report

DIRECTIONS:

Please complete the report for clients referred to the SARAC Resource Center.

VICTIM SERVICES:

This set of questions asks about the provision of direct services to crime victims. Report all victims served through your OVC-funded program in this section.

Demographics: Enter the count of individuals referred

Race/Ethnicity (Self-reported) *

Race/Ethnicity (Self-reported)*

Select all reported

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White Non-Latino or Caucasian
Some other race
Multiple races
Not reported

American Indian or Alaska Native*

Asian*

Black or African American*

Hispanic or Latino*

Native Hawaiian or Other Pacific Islander*

White Non-Latino or Caucasian*

Some other race*

Multiple races*

Not reported*

Gender Identity (Self-reported) *

Gender Identity (Self-reported)*

Select all reported

Male
Female
Other
Not reported

Male*

Female*

Other*

Not reported*

Client Victimization Type *

Enter the count of individuals referred based on victimization type. An individual may be counted in more than one victimization type. An individual may not be counted more than once within the same victimization type.

Client Victimization Type*

Select all reported

Adult Physical Assault (Includes aggravated and simple assault)*

Adult Sexual Assault*

Adults Sexually Abused/Assaulted as Children*

Arson*

Bullying (Verbal, Cyber or Physical)*

Burglary*

Child Physical Abuse or Neglect*

Child Pornography*

Child Sexual Abuse/Assault*

Cyber Crimes*

Domestic and/or Family Violence*

DUI/DWI Incidents*

Elder Abuse or Neglect*

Gang Violence*

Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other*

Human Trafficking: Labor*

Human Trafficking: Sex*

Identity Theft/Fraud/Financial Crime*

Kidnapping (Noncustodial)*

Kidnapping (Custodial)*

Mass Violence: Domestic/International*

Other Vehicular Victimization*

Robbery*

Stalking/Harassment*

Survivors of Homicide Victims*

Teen Dating Victimization*

Terrorism (Domestic/International)*

Other*

Evidence Based Practices

This section of questions asks about Evidence-Based Practices (EBPS) used by the referring partner. Evidence-based programs or practices are best practice models that include program models that have been shown through rigorous evaluation and replication to be effective.

Did you use EBPS when serving this client?*

Yes
No

Which EBP did you use?*

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