Youth Referral/Parent Permission Form

Safe Harbor Youth and Young Adult Program Ages 12-24
Email Referrals to: youth@mnswcc.org
Call 1-800-376-4311
Youth text line 1-218-666-8336
Fax Line: 507-372-4311

Please complete the Youth Referral Form below or download and return the Youth Referral/Parent Permission Form (PDF).

Youth Referral/Parent Permission Form

Referral Date

YOUTH INFORMATION:

First Name *

Last Name *

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Grade

Birthday

County

Age

Email *

Phone *

PARENT/GUARDIAN INFORMATION:

First Name

Language

Last Name

Phone

REFERRING AGENCY INFORMATION:

Agency Name

Phone

Contact Name

Would you like us to check in with you before meeting youth?

Yes

The primary goal of our program is to provide confidential services and support for youth and young adults ages 12-24 who may be vulnerable to any form of domestic violence, sexual assault, sexual exploitation, or human trafficking because of challenging life experiences.

PROVIDE INFORMATION/INCREASE KNOWLEDGE OF:

GROUP CONNECTION:

Interpersonal violence
Healthy/unhealthy relationships
Harassment and its effects
Provide information about survivor’s legal rights and resources
Community programs and referral options

Meet other youth with similar experiences
Life Skills class
Choices 101
1st Thursday
LGBTQ Support Group

PERSONAL ADVOCACY:

EMOTIONAL SUPPORT AND SAFETY SERVICES:

Assistance writing an Order for Protection or Harassment Restraining Order
Assistance writing a Victim Impact Statement or working with County Attorney
Advocate to attend court hearings for support
Support with medical exam, law enforcement interview, or legal meetings and procedures

Provide tools to reduce self-blame and identify anxieties about situation
Create a plan to increase safety
Safe place to talk and share their story
Create healthy ways to process their reactions, thoughts and emotional expression and being aware of self-care options & health
Increase support system, including one-on-one support
Connecting with the Safe Harbor Regional Navigator for services related to sex trafficking and exploitation

Briefly tell us more about this referral:

Dear Parents/Guardians,

Your child is being offered the opportunity to participate in youth programming though the Southwest Crisis Center. Some of the services may include personal advocacy, one on one education services, group therapy and services as well as access to resources and referrals and transportation. Topics covered within the programming may include healthy relationships, setting boundaries, self-esteem, empowerment, goal setting, safety with technology and relevant resources on health and safety.

Youth advocates at the Southwest Crisis Center successfully complete direct and specific training which includes the MN standard of 40 hours of sexual assault advocacy training, as well as continuing education on domestic violence, sexual exploitation of youth, crime victims’ rights and services and many other topics.

If you have any questions, please contact Stephanie Darnell, Youth Program Manager at 507-376-4311 or email at Stephanie@mnswcc.org.

Please fill out and submit the information below, giving approval for your child to participate in the youth programming offered through the Southwest Crisis Center.

Sincerely,

SWCC Youth Staff

PARENTAL/GUARDIAN PERMISSION:

I (parent/guardian entered above), give my child (youth entered above) permission to participate in youth programming at the SWCC.

Your Signature

Date

Parent/Guardian

Phone

Initial if you give permission to the Southwest Crisis Center staff to provide transportation as needed.

Thanks for submitting!