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Screening form

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Screening form

New Resident Screening

Date Submitted:

Your Consent:

Applicant agrees to be truthful and acknowledges that the application isn’t an automatic admission:

Safe Email for Applicant:

Safe Phone Number for Applicant:

Applicant Initials:

Age:

Date of Birth:

What is your race/ethnicity?

White/Caucasian

Black/African American

Hispanic

Native Hawaiian or other Pacific Islander

Multiple Races

Other

CONTACT INFO FOR REFERRING AGENCY:

Form Submitted By:

Agency/Organization Name:

Agency/Organization Location:

Contact Name:

Contact Email:

Contact Phone Number:

Where is the Individual Seeking Services Located (City, State)?

How long have you known the Applicant?

PERSONAL INFORMATION:

Gender/Sex

Are you, or could you be pregnant?

Yes

No

Do you need a program that allows children?

Yes

No

PROGRAM PREFERENCES:

How soon do you need placement?

What type of program are you looking for?

Are you comfortable sharing a bedroom with another woman?

Yes

No

What level of staff supervision would be most helpful to you?

Are you comfortable with a program that is religiously afflicted?

What type of faith-related program options are you comfortable with?

Do you need transportation assistance getting to RU?

Yes

No

Do you require translation to a particular language? If so, please specify

EXPLOITATION INFORMATION:

What type of exploitation are you seeking recovery from? Check all that applies

Sex trafficking

Labor trafficking

Prostitution

Survival sex

Other forms of commercial sex

How was the trafficking activity verified?

How long ago was your last experience with trafficking or exploitation?

Have you previously (or currently) been in a trafficking shelter program? If so, please list the program(s):

LEGAL:

Citizenship:

Check all that apply

I am actively escaping an abuser

I currently have outstanding warrants or legal obligations

I am currently involved in an open or pending investigation

I will be on parole or probation

I am part of a diversion program with court requirements

I am currently registered as a sex offender

None of the above

Brief explanation of your situation:

Have you ever been charged/convicted of violent crimes?:

Yes

No

Do you have any limitations on where you should be placed?

HEALTH:

What are your medical health concerns?

Please list your mental health/cognitive diagnoses:

Please list any current prescription medication(s) that you take:

Can you get a 30-day supply of your medications before you come to RU?

Yes

No

N/A

I need services that accept the following: Check all that apply

Physical disability

Certified service animal

Emotional support animal

Reported self injury

Reported suicidal ideation

Experience episode of psychosis

Used illegal sources in the last 7 days

Used illegal sources in the last 30 days

Used marijuana within a program

Currently taking prescribed medication for opioid treatment

None of the above

If you selected any of the previous, please explain

Do you smoke cigarettes/vape?

Have you ever been in rehab? If so, how many times?

Are you in need of addiction recovery services?

Any special classifications (Please check all that apply)

Deaf/hard of hearing

Blind/Hard of seeing

Immigrant/Refugee

LGBTQ

Veteran

Disabled

Limited English

None of the above

COMMENTS:

Is there anything else we should know?

CONSENT TO THE RELEASE OF THE INFORMATION ABOVE:

First Name

Last Name

Signature:

Sign Here

Office Address

10750 Hammerly Blvd #254,
Houston, TX, 77043

Mailing Adress

225 Matlage Way #1827
Sugar Land, TX 77478

Email Us

rescueusmission@gmail.com

Support

info@rescueusmission.org

Call Emergency

+1 832 646 4232

Rescue Us Mission aims to provide trauma survivors with resources, support, and opportunities for healing and reintegration.

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+1 832 646 4232

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