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Relocate
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Prevention Education
Professional Development
About Us
Our Team
Contact

Recover
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Prevention Education
Professional Development
About Us
Our Team
Contact

Recover
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Emergency Response

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Emergency Response Request

Please fill out this form for emergency response assistance. Our team will review your information and respond as quickly as possible to provide support and care.

Date

This referrals is being provided by

Organization working with a survivor Myself (survivor) Other

If other, please define the relationship:

Full name of individual providing the referral

Full name of survivor needing assistance:

Contact information for the survivor:

Is it safe for Daughters of Worth to contact the survivor?

Yes No Uncertain

What is the best method and timeframe for DOW to contact the survivor?

Survivor's Date of Birth

Where is the survivor currently located? City and state?

Address of the survivor (if known)

Does the survivor meet the criteria for identification as a trafficking victim? (Being compelled by the use of force, fraud, or coercion to conduct commercial sex acts?)

Yes No Uncertain

Is the survivor supportive of this referral, desiring assistance?

Yes No Uncertain

Is the survivor currently safe?

Yes No Uncertain

Explain what has happened that has led to the survivor seeking assistance and what services are needed:

Does the survivor have children?

Yes No Uncertain

If the survivor has children, are they in her custody?*

Yes No Uncertain

If the survivor has children, what are the ages of the children?

Is the survivor in need of detox or inpatient services for substance use disorder?*

Yes No Uncertain

If the survivor needs detox/inpatient services, what are the drugs of choice and when is the last time that she used? How much?

If relocation services are needed, is the survivor willing to relocate out of state?

Yes No Uncertain

Any additional information that is relevant for Daughters of Worth team to know regarding the survivor and request for services:

Upload your Signature

Email of the individual providing referral*

Phone number of the individual providing referral

Dedicated to the recovery, relocation, and restoration of girls and women through unconditional love and trauma-informed care.

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Emergency Response

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252-295-7517
info@daughtersofworth.org
PO Box 2494, Greenville, NC 27836

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