Name
*
First Name
Last Name
Nickname
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Race
Phone
*
(###)
###
####
Email
*
Please list your social media handles.
*
Emergency Contact (First and Last Name)
*
Emergency Contact Phone
*
First Name
Last Name
Are you currently working with an advocate/mentor/case worker now?
Please provide their name.
*
First Name
Last Name
Have you previously participated in a residential or outpatient program?
*
Please provide their name.
*
First Name
Last Name
Please tell us about yourself.
*
What does your typical day look like?
What is your daily activity level?
Please provide your Height and Weight.
Providing your height and weight helps us better understand any specific health, dietary, or accommodation needs to ensure we can offer you the best possible care and support. Your response will be kept confidential and used solely for your safety and well-being.
What level of education have you completed? Please check all that apply.
Do you have a Drivers License or an ID? (Please specify which one) If not, why?
Do you have a history of starting fires?
*
Do you have a history of physical fights?
*
Do you have a history of destroying property?
*
Do you have a history of running away?
*
Please provide the date/age of your first sexual experience.
*
What is the age that you entered the sex industry?
*
Do you have a history of sexual abuse and trauma?
*
What is the age that you were first trafficked/exploited?
*
Are you currently in an abusive situation?
*
Do you currently have any pending legal charges against you? If yes, please list below.
*
Are you currently on probation?
*
Have you ever been in a shelter? If so, where and when?
Please describe your current living situation.
*
Shelter
Apartment
Hote/Motel
With Friends
With Family
On the Streets
House
Jail
Residential Program
Other
Who do you currently live with?
*
Do you have a support animal?
Have you ever used drugs? List them along with date(s) of use and frequency.
*
Are you on any medications or supplements (vitamins)? If so, please list below including dosage.
Are you currently on methadone or suboxone, or have you used them in the past? If so, when?
Are you or could you be currently pregnant?
*
Do you have any dependents?
*
If checked yes, please list their names and ages.
Do you currently have custody of your children?
*
YES
NO
Not Applicable
Do you suffer from or have been diagnosed with any of the following chronic health conditions?
*
TextDo you have a mental health diagnosis? If so, please explain.
Have you previously been hospitalized for psychiatric reasons?
*
If marked yes, please describe the reason/situation and your age at the time.
Have you previously attempted suicide?
*
If marked yes, please describe reason/situation and your age at the time.
Are you currently in contact with someone from the life?
*
If marked yes, please describe that relationship.
How do you deal with anger?
*
How do you deal with frustration?
*
How do you deal with sadness?
*
How do you deal with conflict?
*
Can you tell us in your own words what you are hoping to get out of our program?
*
Why do you think that you need a placement?
*
