Safer Society Foundation, Inc. Resouces and referals for the treatment of sexual abuse

Online Referral Request Form
Important Instructions
Please complete the form below and then press the "Send Referral Form" button to submit your request to Safer Society via e-mail. If you do not feel comfortable sending the request form via e-mail, you may complete the form in your web browser first, then print, and fax it to Safer Society at 802-247-4233 or mail it to Safer Society, PO Box 340 Brandon, VT 05733-0340. We will be unable to reply to your request via e-mail or telephone. Fax numbers MUST be provided in order to reply to a referral. We will aim to fax or mail information back to you within a 24 hour period. Thank you.
Person requesting referral:	Person to fax referrals to (please do not give offender's name)

If other, specify:	Agency
Telephone	Fax Number *required E-Mail
State	Date
PLEASE CLICK OR Fill IN THE APPROPRIATE RESPONSES

Offender's Age	Offender's sex M FM	Any substance abuse? Yes No
Yes No Is offender of average intelligence?		If no, what is IQ?
Yes No Has the offender been adjudicated?		Does offender admit deny
Yes No Has offender been evaluated? (if yes, when?)
Yes No Has offender ever received treatment? (if yes, for how long?)
Yes No Is offender diagnosed with psychosis?
Yes No Other major mental illness (if yes, specify)
How can treatment be paid for? Specify (eg, insurance)
I WOULD LIKE REFERRALS FOR THE FOLLOWING: (Chose one type of referral per request)

City(ies):	Offender is a resident of what state:
State(s):	Offender would also consider residential treatment in the following states:
County(ies):	Tel area code(s):
Names and telephone numbers of treatment providers will be faxed to you. To maintain confidentiality, only the offender's age and sex, and date of request will be used on the return fax.
Safer Society Foundation: A Nonprofit Agency for the Prevention and Treatment of Sexual Abuse