Name
*
First Name
Last Name
Email
*
Date of Birth
*
Gender Identity
*
Current Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Race/Ethnicity
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Non-Latino White
Hispanic or Latina
Other
What languages do you speak?
*
If we do not have an opening in our program, would you be open to one of our sister organizations?
*
Yes
No
a. If yes, what geographical limitations or states do you prefer?
*
If we do not have an opening in our program, would you like to be put on our waitlist?
Yes
No
Which Identification documents do you have?
*
Pick all that apply.
Who referred you?
*
Describe your relationship with your family.
*
How many children do you have?
*
0
1
2
3
4
5
6
More than 6
Do you have a history of substance use?
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Yes
No
Have you ever exchanging sex for money or material goods, including food or shelter for yourself or someone else, e.g. child, family, partner?
*
Yes
No
Have you ever been filmed or photographed in a sexually explicit manner against your will or without your consent?
*
Yes
No
Have you ever been forced to give the money you earn to another person?
*
Yes
No
Do you have a history of prostitution?
*
Yes
No
Have you experienced trafficking?
*
Yes
No
a. Did you experience pimp, familial, gang trafficking or other?
*
b. Did you have a pimp or a trafficker?
*
Yes
No
c. How long have you been out of the life or away from your trafficker?
*
d. Last known approximate location of pimp or trafficker.
*
Do you have a history of experiencing sexual abuse?
*
Yes
No
Do you have a history of experiencing domestic violence?
*
Yes
No
Are you currently in a romantic relationship?
*
Yes
No
Do you have any medical insurance?
*
Yes
No
Do you have SSI or SSDI?
*
Yes
No
a. Do you have a payee or conservator?
*
Yes
No
Do you have any physical disabilities or chronic ongoing conditions?
*
Check all that apply.
Have you ever been hospitalized for psychiatric reasons?
*
Yes
No
Have you ever attempted suicide
*
Yes
No
Have you been diagnosed with DID (Dissociative Identity Disorder)?
*
Yes
No
I am not sure
Have you been diagnosed with schizophrenia?
*
Yes
No
I am not sure
Will you agree to take UA’s?
*
Yes
No
Have you had any gang affiliations (past or present)?
*
Yes
No
Do you have an arrest record?
*
Yes
No
I am not sure
Have you been charged as a sexual offender?
*
Yes
No
Do you have any warrants/pending charges in any state or county?
*
Yes
No
I am not sure
Do you have any other legal obligations?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
What are your allergies?
*
a. Do you require an EpiPen for your allergies?
*
Yes
No
What is your highest level of education?
*
Less than High School
High School Graduate
GED
Some College, no degree
2 Year Degree
4 Year Degree
Masters Degree
Doctorate
What kind of jobs have you had in the past?
*
Are you willing and able to work a job full or part time?
*
Yes
No
I Don't Know
What would you do with this opportunity for change and healing?
*
Give three references, name and number/email, that are not family. We prefer case managers, counselors, POs, or anyone else who is not related.
*
Who is completing this intake form?
*
Person Themselves
Family Member
Friend
Case Manager
Legal Representative
Advocate
By signing or typing my name below, I agree to the program's requirements and agree to have my information stored in a secure, confidential database.
*
