Make a Referral

To make a referral to The Covering House, please download our Service-Referrals Form, complete and email to our Executive Director at lellis@thecoveringhouse.org.

For immediate client assistance please call our administrator on call at:  (417) 425-4818.

Services Referral Form

Date

Referring Agency

Email Address (required)

Telephone Number (required)

Referring Worker

Client Name

Client Date of Birth

Client Age

Client Address

Does your client qualify for:
MedicaidPrivate InsuranceWill Need SponsorshipOther

If Other, please explain:

Living Arrangemenets:
PimpFamily MemberFriendAloneFacilityOther

If Facility, please name:

If Other, please name:

Client Telephone

Alternate Telephone

Emergency Contact Name

Relationship to Client

Emergency Contact Telephone Number

Does the client have children?

Has the client been sexually trafficked or sexually exploited?

If so, what form(s)?
ProstitutionStrippingPornographyEscort ServicePhone SexWeb CamTrading Sex for money, drugs, gifts or survival needs

Has the client been involved in any type of abusive relationship?

If so, what form(s)?
Physical AbuseSexual AbuseEmotional AbuseVerbal AbuseRapeMolestation

Why do you think this young woman would be appropriate for The Covering House's services? Please describe brief history and presenting problems.

Please describe any additional, relevant information: (i.e. If there are any safety plans in place, restrictions in contacting client, etc.)

How receptive is client in being referred to The Covering House? Please describe client's reactions & feelings about being involved in The Covering House.