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 NumberArea CodePhone NumberReferred By *Counselor or Social WorkerFirstLastPhone NumberArea CodePhone NumberEmailPerson Completing Form *FirstLastRelation to ApplicantPlease 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 CSETWhen was the last time you engaged in CSET?CSET historyi.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?FirstLastDoes the FOB go by any alias?Where is the FOB currently located?What is the FOB's date of birth?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 useDrug of choiceCurrent length of sobrietyClean DateABUSE 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?Have you received a Covid vaccine?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.PreviousEmailSubmit
