Freedom For Life Initiative

Thank you for your referral. Please fill out the information below to help us understand the needs of the individual(s) being referred and to facilitate a smooth intake process.

Shelter Referral Form

Referring Organization Information

Organization Name

Contact Person’s Name

Contact Person’s Position

Contact Number

Email Address

Organization Address

Date of Referral

Survivor Information

Survivor’s Initials or Unique Identifier

Age of Survivor

Gender of Survivor

Reason for Referral

Describe the survivor’s current situation and the reason for referral

Specific challenges or needs (e.g., health concerns, safety risks)

Immediate risks or safety concerns

Health and Support Needs

Known health conditions or special needs

Current medications or medical treatment

Other support services (e.g., counseling, legal aid)

Preferred Duration of Stay

Expected duration of shelter support needed

Additional Information

Additional relevant information

By submitting this form, I confirm that I have obtained the survivor’s consent to refer them for shelter services. I also confirm that all information provided is accurate and that our organization agrees to maintain communication with the shelter regarding any ongoing needs or updates for the referred individual.

Freedom For Life Initiative

Office No.6 Sudais Road, by Talata Mafara Road Sokoto, Nigeria.

Let's Talk

Phone 1: +2348036874478
Phone 2: +23426876268

E-mail Us

info@fflinigeria.org