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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


BIRTHDAY
RACE
IF WE DO NOT HAVE A OPENING IN OUR PROGRAM, WOULD YOU BE OPEN TO ONE OF OUR SISTER ORGANIZATIONS?
YES
NO

COMMERCIAL SEXUAL EXPLOITATION & TRAFFICKING (CSET)

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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.

ï‚·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. 

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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) ?*
YES
NO
FAMILY SUMMARY
DO YOU HAVE CHILDREN?
YES
NO
ADDICTION HISTORY
DO YOU HAVE A HISTORY WITH ADDICTION?
YES
NO
ABUSE HISTORY AND RELATIONSHIP STATUS
DO YOU HAVE A HISTORY OF SEXUAL ABUSE?
YES
NO
HAVE YOU EXPERIENCED DOMESTIC VIOLENCE?
YES
NO
ARE YOU CURRENTLY IN A ROMANTIC RELATIONSHIP?
YES
NO
HEALTH HISTORY
DO YOU HAVE MEDICAL INSURANCE?
YES
NO
HAVE YOU RECEIVED A COVID VACCINE?
YES
NO
DO YOU RECEIVE SSI OR SSDI?
YES
NO
HAVE YOU EVER RECEIVED A MENTAL HEALTH DIAGNOSIS
YES
NO
DO YOU HAVE ANY PHYSICAL DISABILITIES, CHRONIC, OR ONGOING CONDITIONS?
YS
NO
ARE YOU CURRENTLY TAKING ANY MEDICATIONS?
YES
NO
HAVE YOU BEEN HOSPITALIZED FOR PSYCHIATRIC REASONS?
YES
NO
HAVE YOU EVER ATTEMPTED SUICIDE?
YES
NO
ARREST HISTORY
DO YOU HAVE PENDING CHARGES OR WARRANTS?
YES
NO
ARE YOU ON PROBATION?
YES
NO
EDUCATION AND WORK HISTORY
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