Referral Form

Schenectady County Safe Harbour Referral Form

Complete as much information as possible. The form does not need to be complete in order to be submitted. Contact Safe Inc. of Schenectady at 518.374.0166 or via email at safeharbourprogram@safeincofschenectady.org with any questions or concerns

Referral Form

Youth Information

Address
Address
City
State/Province
Zip/Postal

Parent/Guardian Information

Address
Address
City
State/Province
Zip/Postal

Referral Info

Youth is referred for
Trafficked for Sex/CSEC
Trafficked for Labor

Involved with Services

Child Protective Services
CAC Involvement
Foster Care Placement
Juvenile Justice
Mental Health Treatment
PINS
Probation Involvement
Runaway/Homeless Youth Program
Advocacy Involvement
Preventative Services
Substance Abuse Treatment
Law Enforcement
Involvement with Other Providers
Race*
Nationality*
Documentation Status*
Ethnicity*
Indicators ( check ALL that apply )
* for data collection purposes only

Submit via email to safeharbourprogram@safeincofschenectady.org or via mail to Safe Inc. of Schenectady @ 1344 Albany Street, Schenectady, NY 12304

**Please include a copy of the youth’s Rapid Indicator Tool and Comprehensive Assessment**