Referral Agency
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Referral Agency Point of Contact
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First Name
Last Name
Referral Agency Contact Email
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Relationship to Applicant
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Law Enforcement/Task Force
Legal Counsel/Court Official
Social Worker/Case Manager
Safe House or Trafficking Shelter
Anti-Trafficking Agency
Friend/Family Member
Self
How long have you known the applicant?
*
By what date do you need placement?
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Applicant Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Gender
*
Our residential home is equipped for biological female residents only at this time.
Male
Female
Other
If other, how do they identify?
Applicant is:
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Our focus is domestic victims at this time.
U.S. Citizen
Legal Foreign National
Undocumented Foreign National
Where is the applicant currently residing?
*
Do you believe the applicant is a victim of commercial sexual exploitation by means of force, fraud, or coercion?
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Yes
No
Does the applicant have any outstanding warrants or legal obligations?
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Yes
No
If yes, please explain.
Is the trafficker in custody?
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Yes
No
N/A
Is there an open or pending case against the trafficker?
*
Yes
No
N/A
Is the applicant currently incarcerated?
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Our program is not an alternative to incarceration. Residents will not be accepted if court mandated - only voluntary applicants are considered.
Yes
No
If yes, please provide a release date.
MM
DD
YYYY
Is (or will) the applicant be on probation/parole?
*
Yes
No
If yes, please provide conditions of probation/parole.
Is the applicant a flight risk?
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Yes
No
Is there a chance the applicant could be pregnant?
*
Our residential home is not equipped for pregnant residents at this time.
Yes
No
Is the the applicant actively self harming?
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Yes
No
Is the applicant a suicide risk?
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Yes
No
Does the applicant have at least 30 days sobriety/clean time?
*
Yes
No
Is the applicant on prescribed pharmacology?
*
We do not allow stimulants of any kind, including for the purpose of ADHD management. We also have guidelines on prescribed sleep aids, medications for seizure disorders, and anti-psychotic medications. We will require a complete list of medications the applicant is currently taking and the purpose.
Yes
No
Does the applicant have any severe psychiatric issues?
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We are not equipped for residents suffering from Schizophrenia or Schizoaffective Disorder. We do not have medical personnel on staff at this time.
Yes
No
Does the applicant have any immediate health concerns or physical limitations?
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Our program is robust in nature and requires physical participation. All bedrooms are located on the second floor with no elevator access. Residents are moving up and down the stairs frequently throughout the day. We do not have medical personnel on staff at this time.
Yes
No
If yes, please explain.
Does the applicant need a program that accepts dependent children?
*
We are not equipped for residents with children at this time.
Yes
No
Does the applicant know that we are a faith-based organization, but offers both faith-based and secular-based programming?
*
We do not require our residents to be of the Christian faith, but residents are exposed to Christian symbols such as crosses hanging on the wall and conversations that may include the name of Jesus. We do not allow witchcraft, wiccan, or satanic practices in the program.
Yes
No
Has the applicant previously (or currently) been in a trafficking shelter program?
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Yes
No
If yes, where, when, and for what reason did they leave?
Have you presented the idea of Redeemed Ministries' Sparrow House to the applicant?
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Yes
No
Do you believe the applicant is receptive to a long-term residential program such as ours?
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Some individuals may prefer short-term programs or transitional programs. Our program residents are not allowed to have a cell phone for the first year they are in the safe house, and they have limited internet access. Residents are eligible to begin working outside of the program at approximately one year. Before that they become eligible to work in the organizations economic empowerment program once they have completed 2 full semesters of programming. They will earn money while in the economic empowerment program.
Yes
No
If yes, please explain why?
Please provide any additional pertinent information regarding this applicant or the referral.