– Referral – If you would like to refer a child to our program, please use the following form. Child Name Age Date of Birth Message Grade School Address Phone Name of Deceased Parent: Date of Homicide: City/State of Homicide: Parent or Guardian of Child: Identify if the child lives with parent or guardian: Current or past victim advocacy agency involvement: Has the child received mental health treatment: How did you learn about the Healing Pathway Program: 4 + 5 = Submit