Survivor Services – Clay & Oak

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Even in some of the most difficult storms, oak trees remain.

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Now accepting Restorative Care referrals for residential placement in January 2026.

Are you an advocate, organization or ministry who wants to reffer a survivor to our program? Please fill out the form below.

To speak to our intake coordinator directly, please contact Ashley Parker at ashley.p@clayandoak.org.

Please enable JavaScript in your browser to complete this form.

Your Name *

First

Last

Your Job Title *

Your Organization *

What organization are you referring from.

Your City & State *

Where are you referring from.

Email *

Your Phone Number *

What time of day is best to contact you? *

Potential Applicants Name *

First name only please

What is her age? *

& or was

Is she a US citizen? *

Yes
No

What is her current living situation? *

Please include how long she has been at this location and any living details you believe would be helpful to know in her care.

Please list all of her known mental health diagnoses: *

Please note that a diagnosis does not keep someone from acceptance. We want the whole picture to know how to best care for her.

Is she currently pregnant or have children under her custody? *

Yes
No
Unkown

Is she abe to exercise and climb stairs without assistance? *

Yes
No
Unkown

At this time, we are not wheelchair accessible. Accessing the bedrooms requires using stairs.

Please list all drugs ever used: *

Drug use does not exclude someone from acceptance. We want the whole picture to know how to best support her sobriety.

When was her last known drug use? *

Does she drink alcohol? *

Yes
No

When was her last known alcohol use? *

Is she in need of detox? *

Yes
No

Does she have any open warrants in any state? *

Yes
No

Is she currently on parole or probation? *

Yes
No

Does she have any pending court dates? *

Yes
No

Is she open to a faith-based program? *

Yes
No

Has she completed an emergency or stabilization phase or detox recovery program at another organization? *

Please include the organization name and date of completion.

Any other details or information that may be helpful for the Clay & Oak intake team: *

Please include if the placement needed is urgent or time-specific.

© 2024 Clay & Oak | Email: info@clayandoak.org

National Trafficking Hotline: 1-888-373-7888

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