Strides AHT Program Referral Form

If you would like to access our program’s services, please complete the form below to the best of your ability. You can complete it on your own or with the assistance of another service provider. If you require any assistance in completing the form, please call 416-438-3697 x. 13333 or email ahtintake@stridestoronto.ca.

Make a Referral

Please complete all sections, then click SUBMIT to send your referral.

Please enable JavaScript in your browser to complete this form.

1Section 1

2Section 2

3Section 3

4Section 4

5Section 5

6

7

Section 1: Personal Information

Name *

Pronouns *

she/her, he/him, they/them, etc.

Date of birth (MM/DD/YYYY) *

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Age *

Gender *

Ethnicity *

Religion and/or cultural identity *

Do you identify as FNIM? *— Select Choice —YesNo

FNIM stands for First Nations, Indigenous, or Métis.

First language *

Do you need translator services? *— Select Choice —YesNo

Please select the option that best describes your current immigration status. *

• Canadian Citizen
• Convention Refugee
• Refugee Claimant
• Student Visa
• Permanent Resident
• Other

Please specify: *

Next

or voicemail birth

Section 2: Contact Information

Phone # *

Is it okay to leave a voicemail and text this #? *— Select Choice —YesNoOnly textOnly voicemail

Alternative telephone #

Is it okay to leave a voicemail and text this #?— Select Choice —YesNoOnly textOnly voicemail

Preferred email address *

Is it okay to email this address? *— Select Choice —YesNo

Where are you currently residing? *

• Temporary
• Permanent
• No fixed address
• Staying with friends
• Shelter
• Other

Please specify: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Are there any other details you’d like us to be aware of when contacting you? *

PreviousNext

Section 3: Other Services & Accommodations

1. We strive to make our services as accessible as possible. Are there any accommodations we can provide that would make it easier for you to participate in our services or to communicate with us? — Select Choice —YesNo

If yes, please specify: *

2. Do you have any other agencies currently supporting you that would be helpful for us to know about?— Select Choice —YesNoPrefer not to answer

If yes, please specify: *

3. We have a Youth In Transition (YIT) worker who specializes in supporting youth 16-24 who have been involved with Children’s Aid and also experienced/been at risk of exploitation or trafficking. Do you have current/past involvement with CAS? *— Select Choice —YesNoUnsurePrefer not to answer

4. Are you currently receiving counselling or psychotherapy? *— Select Choice —YesNoUnsurePrefer not to answer

5. Are you a client of your local CARE Unit (child welfare or Police)? *— Select Choice —YesNoUnsure

PreviousNext

Section 4: History

Do you self-identify as being:

1. Currently at risk of sexual exploitation/sex trafficking? *

• Yes
• No
• Unsure

2. Previously subjected to sexual exploitation/sex trafficking? *

• Yes
• No
• Unsure

3. Currently subjected to sexual exploitation/sex trafficking? *

• Yes
• No
• Unsure

4. Involved in sex work currently? *

• Yes
• No
• Unsure

5. Involved in sex work in the past? *

• Yes
• No
• Unsure

6. Do you have any current concerns for your safety (physical, financial, psychological, emotional, etc.)? *

• Yes
• No
• Unsure

7. Is there anything you’d like us to know about your safety concerns? *

PreviousNext

Section 5: Immediate Needs

1. What service(s) do you think you are interested in receiving through the Anti-Human Trafficking Live-In Treatment Program? Please select all that apply. *

• Peer Support
• Skill Enhancement
• Case Management Support
• Individual Therapy

2. I understand that the live-in treatment program is voluntary, and I am interested in being referred. *

• Yes
• No

3. Below are some common concerns our clients often have. Please select any that you are looking for assistance with. *

• Income security support (e.g. OW, ODSP)
• Medical care
• Child care supports
• Applying to housing resources (e.g. shelters, transitional, long-term, etc.)
• Legal support
• Safety planning
• Support with basic needs (e.g. food security, transportation, clothing)
• Sexual health support
• Goal setting
• Court accompaniment
• Identification documents
• Advocacy
• Education support (e.g., school enrolment)
• Family support
• Parenting support
• Harm reduction/substance use support
• Peer support
• Employment support
• Other

If you selected ‘other’, please specify: *

Next

Is this referral coming from an agency on your behalf? *

• Yes
• No

If this referral is coming from an agency on your behalf, please specify who you consent to the Anti-Human Trafficking Live-in Treatment team contacting with information about your application. *

• Me
• Agency/Worker
• Both

For worker at the referring agency

Referring agency *

Name of worker *

Position/role *

Phone # *

Email *

How long have you been working with the client? *

Please list any programs or services the individual is currently involved in within your agency: *

Next

Thank you for taking the time to fill out our referral form. Please make sure the form is completed to the best of your ability. Protecting client privacy is critical to Strides Toronto.

Updating preview…

This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You can also go back to make changes.

Previous

Submit