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SURVIVOR APPLICATION FORM

Residential Program Application

*New application takes 20-40 minutes to complete. Please ensure you have the following information before you begin, as progress cannot be saved: 
  • Commercial Sexual Exploitation & Trafficking History

  • Family Summary

  • Addiction History

  • Abuse History 

  • Health History 

  • Arrest History 

  • Education and Work History

IF WE DO NOT HAVE A OPENING IN OUR PROGRAM, WOULD YOU BE OPEN TO ONE OF OUR SISTER ORGANIZATIONS?

COMMERCIAL SEXUAL EXPLOITATION & TRAFFICKING (CSET)

WHAT IS CSET?


COMMERCIAL SEXUAL EXPLOITATION: ANY SEXUAL ACTIVITY THAT IS TRADED OR EXCHANGED FOR SOMETHING OF VALUE (OR THE PROMISE OF SOMETHING OF VALUE), OFTEN FOR THE PURPOSE OF SURVIVAL.

 SEXUAL ACTIVITY ALSO INCLUDES PORNOGRAPHY, STRIPPING, EXOTIC DANCING, ESCORTING, EROTIC MASSAGE, AND STREET EXPLOITATION.

 SOMETHING OF VALUE INCLUDES BUT IS NOT LIMITED TO, MONEY, A PLACE TO STAY, FOOD, CLOTHES, RENT, TRANSPORTATION, DRUGS, MEDICATION, OR SURVIVAL. 

TRAFFICKING: ANY COMMERCIAL SEXUAL ACTIVITY WHERE THERE IS A THIRD-PARTY EXPLOITER ( "DADDY", PARTNER, BOYFRIEND, TRAFFICKER, MANAGER, FACILITATOR, FAMILY MEMBER) THAT AIDS IN THE COMMERCIAL SEXUAL EXPLOITATION OF AN INDIVIDUAL. 

DO YOU HAVE A HISTORY WITH COMMERCIAL SEXUAL EXPLOITATION & TRAFFICKING (CSET) ?*
FAMILY SUMMARY
DO YOU HAVE CHILDREN?
ADDICTION HISTORY
DO YOU HAVE A HISTORY WITH ADDICTION?*
ABUSE HISTORY AND RELATIONSHIP STATUS
DO YOU HAVE A HISTORY OF SEXUAL ABUSE?
HAVE YOU EXPERIENCED DOMESTIC VIOLENCE?
ARE YOU CURRENTLY IN A ROMANTIC RELATIONSHIP?
HEALTH HISTORY
DO YOU HAVE MEDICAL INSURANCE?
HAVE YOU RECEIVED A COVID VACCINE?
DO YOU RECEIVE SSI OR SSDI?
HAVE YOU EVER RECEIVED A MENTAL HEALTH DIAGNOSIS
DO YOU HAVE ANY PHYSICAL DISABILITIES, CHRONIC, OR ONGOING CONDITIONS?
ARE YOU CURRENTLY TAKING ANY MEDICATIONS?
HAVE YOU BEEN HOSPITALIZED FOR PSYCHIATRIC REASONS?
HAVE YOU EVER ATTEMPTED SUICIDE?
ARREST HISTORY
DO YOU HAVE PENDING CHARGES OR WARRANTS?
ARE YOU ON PROBATION?
EDUCATION AND WORK HISTORY

Thanks for submitting!

Contact

Email:

stephanie.rocha@beyondtrafficking.com

Phone:

325-338-2166

325 864-5418

National Human Trafficking Hotline

1 (888) 373-7888

Get Quarterly Updates

Thanks for submitting!

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