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:

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

Do you need a program that allows children?

Yes

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

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

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

Brief explanation of your situation:

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

Yes

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

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?

COMMENTS:

Is there anything else we should know?

CONSENT TO THE RELEASE OF THE INFORMATION ABOVE:

First Name

Last Name

Signature:

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New Resident Screening

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