Referrer Information

Referrer Information

Referrer Information

Referrer Information: In order to fill out the form below, please provide your contact information.

Referrer Name:

Title:

Relationship to the UC:

Email:

Phone Number:

Young Center Team Closest to Child:

Note:

The New Jersey Released team works only with children who are released from ORR custody into the New Jersey community. If a child is in ORR custody in New Jersey, please refer them to the New York City team.

Section A: Referral

The William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008 section 235(c)(6) authorizes the Secretary of Health and Human Services to appoint independent child advocates for child trafficking victims and other vulnerable unaccompanied children. This appointment authority has been delegated to the Office of Refugee Resettlement (ORR). ORR uses this form to determine whether a Child Advocate shall be appointed and to document the Child Advocate's appointment for unaccompanied children (UC) in ORR custody.

1. Referral Information

To be completed by the individual referring the UC for child advocate services.

Referrer Name:

Relationship to the UC:

Date of Referral:

2. UC Information

First Name:

Middle Name:

Last Name:

Date of Birth:

Language(s) Spoken by UC:

A#:

The A# must be a 7, 8 or 9 digit numeric value in this format: ###-###-###

Country of Origin:

Care Provider Name:

Date of Admission:

3. Reason for Referral

Check all that apply.

UC is between the ages 0-12:

UC is placed in a residential treatment center or therapeutic facility:

UC is pregnant or parenting:

UC has a physical or mental disability:

UC is a national from a country known to traffic children:

UC has been identified as a possible child trafficking victim (Interim Assistance Letter, Eligibility Letter, etc.):

UC has a criminal or delinquency history and/or is placed in a staff secure facility or secure facility, and there are outstanding issues affecting the UAC's release or discharge plan:

UC has been a victim of a crime:

UC will turn 18 in less than six months of placement and family reunification is unlikely:

UC is not proficient in a language spoken by staff at the UAC's care provider, and there is no accessible interpreter routinely available:

UC is identified as being eligible for legal relief:

UC has a credible fear of returning to their country of origin and/or are seeking voluntary departure despite concerns about their safety in their home country:

UC lacks appropriate legal representation, or there is a good faith belief that the UAC's legal representative has ties to child trafficking or criminal activity:

UC is expected to have a protracted stay of over 120 days in ORR custody:

UC's potential sponsor is undergoing a home study:

UC is unable to make an independent decision:

Other case where the UC is considered to be exceptionally vulnerable:

Explain Here:

TYC Portal

Referrer Information

Referrer Information

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