Regionalized Human Trafficking Recovery Taskforce Of Greater Hartford Referral Form

RHTRT Referral Form

Please complete the following form to make a referral to the RHTRT. Please provide as much information as you can. If you have partial information, please include that partial information. If you have any questions, please call us at 860-994-6994.

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* 1. Today's Date

Date / Time

Date

Time

AM/PM

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* 2. Referral Source:

Community Provider

DCF HART Liaison

Other DCF

Federal Law Enforcement

Human Trafficking Agency/Provider

Local Law Enforcement

MDT Coordinator

MDT member

Self Referral

State Police

Tribal Law Enforcement

Other (please specify)

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* 3. Referring Entity Information:

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. Are you able to facilitate an introductory meeting with the suspected victim?

Yes

Willing to discuss

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* 5. Location of suspected trafficking.

Avon

Bloomfield

Canton

East Hartford

Farmington

Glastonbury

Hartford

Manchester

South Windsor

West Hartford

Windsor

Unknown

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* 6. Is law enforcement currently involved?

Yes

Unknown

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* 7. If yes, date report was made, if known

Date

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* 8. If known, please enter name of assigned officer.

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* 9. If no, do you know why law enforcement isn't involved?

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* 10. Contact information of suspected victim:

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 11. Alias/street name of suspected victim:

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* 12. Date of birth of victim.

Date

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* 13. If the victim is a minor, has a DCF Careline report been made?

Yes

Unknown

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* 14. If yes, date of the Careline report.

Date:

Date

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* 15. Name of legal guardian and contact information.

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* 16. Preferred language of the victim:

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* 17. Gender of victim

cisgender female

cisgender male

transgender female

transgender male

non-binary/non-conforming

prefer not to respond

unknown

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* 18. Is victim homeless or at risk of homelessness?

Yes

Unknown

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* 19. Does the victim have a child or other dependent in their care?

Yes

Unknown

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* 20. Please describe any cultural considerations and/or disability information that we should be aware of.

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* 21. Type of suspected trafficking?

sex trafficking

labor trafficking

sex and labor trafficking

Unknown

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* 22. Which of the following indicators of human trafficking are present? Please select all that apply.

Online explicit/nude photos

Parties at hotels/motels

Has multiple hotel key cards

Unexplained gifts (phone, clothes, etc.)

Presence of person who controls/speaks for them

Suspicious bruises/injuries

Victim is uncertain about where they have been

Use of language of "the life"

Chronic STD's

Worsening use of substances

In debt to employer

Unable to leave/quit a job

Living in poor conditions at place of employment

Excessive work hours with few or no breaks

Unable to access their vital documents (birth certificate, passport, visa, driver's license, green card, etc.)

Movements are restricted by controlling person

Reports of exchange of sex for something of value

Gang affiliation

Minors: skipping school, truancy

Minors: runaway events

Minors: much older boyfriend or girlfriend

Minors: falling asleep at school

Minors: breaking curfew

Other (please specify)

Question Title

* 23. Contact information for traffickers, if known

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Regionalized Human Trafficking Recovery Taskforce Of Greater Hartford Referral Form

RHTRT Referral Form

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* 1. Today's Date

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* 2. Referral Source:

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* 3. Referring Entity Information:

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* 4. Are you able to facilitate an introductory meeting with the suspected victim?

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* 5. Location of suspected trafficking.

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* 6. Is law enforcement currently involved?

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* 7. If yes, date report was made, if known

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* 8. If known, please enter name of assigned officer.

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* 9. If no, do you know why law enforcement isn't involved?

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* 10. Contact information of suspected victim:

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* 11. Alias/street name of suspected victim:

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* 12. Date of birth of victim.

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* 13. If the victim is a minor, has a DCF Careline report been made?

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* 14. If yes, date of the Careline report.

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* 15. Name of legal guardian and contact information.

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* 16. Preferred language of the victim:

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* 17. Gender of victim

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* 18. Is victim homeless or at risk of homelessness?

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* 19. Does the victim have a child or other dependent in their care?

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* 20. Please describe any cultural considerations and/or disability information that we should be aware of.

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* 21. Type of suspected trafficking?

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* 22. Which of the following indicators of human trafficking are present? Please select all that apply.

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* 23. Contact information for traffickers, if known

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* 24. Please describe reason for referral. Indicate any safety concerns and any other information that will be helpful.