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. As part of the application process, we will be asking personal questions that may include details about your experience with trafficking, your personal history, and medical and legal matters. Your responses are important in helping us understand your situation and provide the best possible support and resources. Please be assured that all information you share will be kept confidential and used solely to assist your care and recovery. 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 Email[email protected]Phone Number *Area CodePhone NumberAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact *FirstLastRelationship to Applicant *Phone Number *Area CodePhone NumberReferred By *Case Manager *FirstLastPhone Number (Please Include Area Code)Email *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, agencySATANIC RITUAL ABUSE (SRA) Form have to SRA refers to allegations of systematic and ritualistic abuse that purportedly involves the worship of Satan or other dark forces. Survivors may describe a range of experiences, including physical, sexual, and psychological abuse, as well as participation in rituals with occult themes.Do you identify as being a survivor of SRA? *YesNoSRA history *Who do you live with now? *Who did you live with in the past? *Can you describe your current and past living conditions? *Have you ever been forced to do things you didn't agree to? *YesNoHave you ever felt coerced or pressured into exchanging sexual acts in order to obtain money, housing, drugs, or safety? *YesNoHas anyone ever threatened you or your family to make you do something you didn't want to do? *YesNoHas anyone ever taken your documents away or kept them from you? *YesNoHas anyone threatened to report you to immigration or law enforcement if you don't do what they say? *YesNoHave you ever been afraid of being arrested or deported because of your situation? *YesNoFAMILY SUMMARYDescribe your relationship with your family. *Do you have children? *YesNoNumber of children, name(s), age(s), and custody arrangements. (If CPS is involved, include the county that the case will be held in). **If DCS is involved, include the county that the case will be held in.Are you currently interested, or in the process of reunification with your child/children? If yes, please explain: *Are you currently working with Child Protective Services (CPS), law enforcement, or any other agencies on reunification? *Are you currently pregnant or caring for a child? *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 any visitation/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, drug and alcohol treatment, intensive outpatient programs (mental health, substance use, etc.) and/or recovery programs you have attend. Please include the name of the program, the date of service, how long you attended, and what happened). *Have you ever received a mental health diagnosis? *YesNoPlease list all diagnoses. *Who provides you with your medical treatment? *Do you have any physical disabilities or conditions? *YesNoPlease explain in detail any physical limitations, chronic, or ongoing conditions you may have.Are you currently taking any medications? *YesNoWhat medication are you taking? (Please list all and include medication name, dose and reason for taking it). *Have you been hospitalized for psychiatric reasons? *YesNoWhen and where were you hospitalized for psychiatric reasons? Please include hospital name, date and reason for hospitalization. *Have you ever attempted suicide? *YesNoHow and when did you make those attempts? *LEGAL HISTORYDo you have pending charges or warrants? *YesNoPlease detail pending charges inside/outside Northampton/Lehigh counties. *Specify if any of your charges are considered felonies.Please list pending court dates: *Number of arrests: *Number of incarcerations: *Please list all charges and dates: *Are you on probation? *YesNoCounty *PO Name *FirstLastPO Phone Number *Area CodePhone NumberAre you currently incarcerated? *YesNoWhere? *Release date? *Conditions of release: *MOBILITYCan you walk for extended periods (ex. 20 minutes at a time)? *YesNoIf no, please explain. *Are you able to go up and down stairs? *YesNoIf not, please explain. *Do you have reliable transportation? *YesNoDo you have access to a car? *YesNoDo you have any specific transportation or mobility needs? *EDUCATION & WORK HISTORYWhat is your highest level of education? *Describe your work history. *NextUpdating preview…This is a preview of your submission. 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