Please enable JavaScript in your browser to complete this form. - Step 1 of 2Is this a new application or a weekly check in? *New ApplicationWeekly Check InThis 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**This application will be forwarded to our Intensive Outpatient team.Applicant's Name *FirstLastAlias Name (If Applicable)FirstLastRace *American Indian/Alaska NativeAsianBlackWhiteOtherPrimary Language *Secondary LanguageDate of Birth (MM/DD/YY) *Email (We will use this to contact you) *EmailConfirm Emailexample@example.comPhone Number *Area CodePhone NumberAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact *FirstLastRelation to Applicant *Phone Number *Area CodePhone NumberReferred By *Counselor or Social Worker *FirstLastPhone NumberArea CodePhone NumberEmail *Person Completing Form *FirstLastRelation to Applicant *Please describe any updates you have to your application. *If we do not have an opening in our program, would you be open to one of our sister organizations? *YesNoDo you have any geographic limitations or state preferences (if they can be accommodated)? *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)? *YesNoNumbers of years of CSET *When was the last time you engaged in CSET? *CSET history *i.e. streets, motels, specific areas of town, backpage, agencyFAMILY SUMMARYDescribe your relationship with your family. *Do you have children? *YesNoNumber of children, age(s), and custody arrangements. *If DCS is involved, include the county that the case will be held in.Are you pregnant or have you recently had a child and are looking to be a part of our Mountain Laurel House two-year residential program for mothers and babies? *YesNoIf pregnant, when is your due date? *If you recently had a baby, what is their name? *FirstLastWhat is the age of your baby? *What is the sex of your baby? *What is father of the baby's (FOB) name? If you prefer not to answer, please put N/A (not applicable) in first block. *FirstLastIf FOB goes by an alias, please list. If you prefer not to answer, please put N/A. *Where is the FOB currently located? If you prefer not to answer, please put N/A *What is the FOB's date of birth? If you prefer not to answer, please put N/A. *Is the FOB involved in the baby's life? *YesNoDoes the FOB pay child support? *YesNoAmount of child support? *Please describe custody arrangement. *Where is the baby receiving medical care? *Contact information for medical provider(s). *Date of last medical visit. *Please list last known shots/vaccines. *ADDICTION HISTORYDo you have a history with addiction? *YesNoYears of drug use *Drug of choice *Current length of sobriety *Clean Date *ABUSE HISTORY & RELATIONSHIP STATUSDo you have a history of sexual abuse? *YesNoWho did this occur with? *Do you still have a relationship with this person? *Have you experienced domestic violence? *YesNoAre you currently in a romantic relationship? *HEALTH HISTORYDo you have medical insurance? *YesNoWho is your provider? *Do you receive SSI or SSDI? *YesNoDo you have a payee or a conservator? *YesNoWhere is your payee or conservator located? *List any inpatient, A&D treatment, IOP, and/or recovery programs in which you have participated. *Have you ever received a mental health diagnosis? *YesNoPlease list all diagnoses. *Who provides you with your mental health treatment? *Do you have any physical disabilities, chronic or ongoing conditions? *YesNoAre you currently taking any medications? *YesNoWhat medication are you taking? (list all) *Have you been hospitalized for psychiatric reasons? *YesNoWhen and where were you hospitalized for psychiatric reasons? *Have you ever attempted suicide?YesNoHow and when did you make those attempts? *ARREST HISTORYDo you have pending charges or warrants? *YesNoPlease detail your arrest record (if applicable). *Specify if any of your charges are considered felonies.Specify any charges pending outside Lehigh or Northampton counties? *Are you on probation? *YesNoCounty *PO Name *FirstLastPO Phone Number *Area CodePhone NumberEDUCATION & WORK HISTORYWhat is your highest level of education? *Describe your work history. *NextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousCommentSubmit
