Hānai Connections

Survivor Referral Form

Use this form to refer a child or an adult survivor of trafficking or exploitation to Hānai Connections. For child referrals, the parent or guardian must know about and agree to the referral. Adult survivors may also use this form to refer themselves. If a service provider or community member is submitting on behalf of an adult survivor, the adult must know and agree to the referral. If you are referring more than one individual, please complete a separate form for each person.

Who is completing this form? *

I am an adult referring myself.

I am a parent/guardian referring a child.

I am a service provider referring a client.

I am a community member referring someone I know.

Who are you referring? *

An adult (18+)

A child/minor (under 18)

Survivor Consent

I consent to this referral and agree to be contacted by Hānai Connections staff. *

Yes

Parent/Guardian Consent

I conset to this referral for my child and agree to be contacted by Hānai Connections staff. *

Yes

Parent/Guardian Consent and Contact Permissions

Has the parent/guardian of this child consented to this referral and agreed to be contacted by Hānai Connections staff? *

Yes

Adult Referral Permissions

Has the individual consented to this referral and agreed to be contacted by Hānai Connections staff? *

Yes

Referrer Information

Your Name (Referrer) *

Organization (if applicable)

Role/Title (if applicable)

Your Phone No. *

Safe Email *

Best Time to Contact You *

Your Relationship to the Survivor *

Parent/Guardian Information

Parent/Guardian 1 Name *

Parent/Guardian 1 Phone *

Parent/Guardian 1 Email *

Best Time to Contact Parent/Guardian 1

Parent/Guardian 2 Name (Optional)

Parent/Guardian 2 Phone (Optional)

Parent/Guardian 2 Email (Optional)

Best Time to Contact Parent/Guardian 2 (Optional)

Survivor Information

Name of the Survivor (or Your Name if Self-Referring) *

Age *

Safe Phone No. *

Safe Email *

Best Time to Contact

Support Needs

Brief description of needs *

Current situation *

Supports currently in place (formal & informal) *

Safety Considerations

Any safety concerns we should be aware of?

Unable to Proceed at This Time

To protect the safety and privacy of the individual, we’re unable to continue this referral unless they, or their parent/guardian, are aware of and have agreed to be contacted. Thank you for understanding. You’ve reached the end of this form and may now close the window to exit.

Additional Notes

Is there anything else youʻd like us to know?