A Project of Nevada Partnership for Homeless Youth
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Youth Interest Form
Parent/Guardian Interest Form
Service Provider Interest Form
Service Provider Interest Form

ThisĀ formĀ is for service providers who would like to refer a client to the Power ON! Program.

Power ON! is a community collaboration between Nevada Partnership for Homeless Youth, Big Brothers Big Sisters of Southern Nevada, The Gay and Lesbian Community Center of Southern Nevada and The Embracing Project. Through the network and expertise of each agency, youth who are at-risk of or are victims of Commercial Sexual Exploitation or Domestic Sex Trafficking will be able to receive direct services and mentorship. The questions below are designed to better understand the youth’s needs so that appropriate services may be provided.

 

Referral Information:


Agency

Your Name (required):

Your Email (required):

Contact Number (required):

Position/Title:

Youth Information:


Youth Full Name (required):

Youth Preferred Name:

Date of Birth (required):

Age (required):

Gender Identity:

Race:

Address:

Zip Code:

School (please write N/A if youth has stopped attending school or dropped out):

When is the best time for a Power ON! Match Support Specialist to contact the youth?

How would the youth like to be contacted? Please Provide:
PhoneEmailSocial Media

If Social Media, please enter name and add handle:

Email (required):

Phone (required):

Best Contact for Parent/If parent cannot or should not be contacted for any reason, please explain:
PhoneEmail

What is the youth's living situation?

Please check where the youth identifies:
Is there any evidence or reason to believe the youth is a victim of commercial sex exploitation and/or domestic minor sex trafficking?
YesNo

Does the youth have a history with the juvenile justice system?
YesNo

Does the youth have a history with the foster care system?
YesNo

Does the youth identify as LGBTQ?
YesNo

Has the youth ever traded sex for money, food or shelter that you know of?
YesNo

Has the youth ever run away from home?
YesNo

Has the youth dropped out of school?
YesNo

Has the youth been involved with a gang or is currently active in a gang?
YesNo

Is the youth currently experiencing homelessness?
YesNo

Has the youth experienced or witnessed physical, sexual, emotional or mental abuse?
YesNo

Permission:
Thank you for completing this Power ON! interest form. By submitting this form, the referring service provider has confirmed that the youth being referred has given explicit permission to submit and release the information above to the Power ON! program. Through this submission, Power ON! is granted express permission to contact the youth and/or their legal guardian through the contact information provided on this interest form.

Please type your full name (required):

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