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Regionalized Human Trafficking Recovery Taskforce Of Greater Hartford Referral Form

RHTRT Referral Form

Please complete the following form to make a referral to the RHTRT. Please provide as much information as you can. If you have partial information, please include that partial information. If you have any questions, please call us at 860-994-6994.
1.Today's Date
Date / Time
Time
:
2.Referral Source:
3.Referring Entity Information:
4.Are you able to facilitate an introductory meeting with the suspected victim?
5.Location of suspected trafficking.
6.Is law enforcement currently involved?
7.If yes, date report was made, if known
Date
8.If known, please enter name of assigned officer.
9.If no, do you know why law enforcement isn't involved?
10.Contact information of suspected victim:
11.Alias/street name of suspected victim:
12.Date of birth of victim.
Date
13.If the victim is a minor, has a DCF Careline report been made?
14.If yes, date of the Careline report.
Date:
15.Name of legal guardian and contact information.
16.Preferred language of the victim:
17.Gender of victim
18.Is victim homeless or at risk of homelessness?
19.Does the victim have a child or other dependent in their care?
20.Please describe any cultural considerations and/or disability information that we should be aware of.
21.Type of suspected trafficking?
22.Which of the following indicators of human trafficking are present? Please select all that apply.
23.Contact information for traffickers, if known
24.Please describe reason for referral. Indicate any safety concerns and any other information that will be helpful.