Intake

482 Collective | Pre-Intake

Sometimes asking for help is
the bravest move you can make

Need help?

We support women, children and individuals from marginalized communities who are struggling with poverty after fleeing human trafficking and other gender based violence including: intimate partner/domestic violence, sexual assault, and physical/emotional abuse.

Please have your case manager/crisis worker/police officer fill out the pre-intake form below and we will be in touch with you within 6-9 days. If you are in crisis and require immediate assistance, please call 911.

Please note: We CANNOT accept referrals made by family or friends and we no longer accept self-referrals. The person in need MUST contact us through a case manager/crisis worker/police officer or community organization.

Pre-Intake Form
Must be filled out by Case Manager/Crisis Worker/Police Officer

Referred by

* Indicates required field

Name *

First

Last

Email *

Name of referring organization *

Eligibility Criteria

Client MUST meet all 3 parameters: *

Has fled human trafficking or gender based violence within the past year Is a Permanent Resident / citizen of Canada Is currently struggling with poverty

Year client fled abuse *

Month client fled abuse *

Please only refer clients who qualify for our services

Client Info

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone number *

Date of Birth

Month *

Day *

Year *

Is your client pregnant? *

How many children does client have? *

Does your client have access to their children? *

Client is a survivor of: *

Income Bracket *

Does client require an interpreter? If yes, referring organization must provide one *

Safety Info

Is client currently living with POC? *

Does client have a Protection Order in place? *

Does the abuser have knowledge of client's current address? *

Is the abuser stalking, harassing, or showing up randomly? *

Please provide a brief summary of your client's SITUATION *

If after 3 attempts we cannot reach your client, would you like to be updated by email *

Submit

Thank you for your referral

What your client can expect after you submit a pre-intake form on their behalf:

We will contact your client by phone or email within 6-9 business days to set up an intake
The intake process will take approximately 15-25 minutes
If after 3 attempts, we cannot reach your client, we will notify you by email if you have selected this option on the pre-intake form
If we cannot directly help your client ourselves, we will make every effort to provide them with additional referral resources

Download our current referral process for your files:

482_referral_process_sept2022.pdf
File Size:	155 kb
File Type:	pdf

Download File

image: umitbus

482 Collective | Pre-Intake​

​Sometimes asking for help is​the bravest move you can make