Intake Application – Form

INTAKE APPLICATION

Innocence Freed offers a faith-based, trauma-informed recovery program and virtual & community-based support groups incorporating Animal-Assisted Learning & Therapy for female survivors of human trafficking and sexual exploitation, ages 12 – 18 and 19 +.

Staff Name

Interview Date

B. CLIENT GENERAL INFORMATION

First and Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Email Address

Referred by Name

Phone

Is it safe to call/leave a message on your phone?YesNo

Birth Date

Age

US CitizenYesNo

What gender do you identify withMaleFemaleOther (please specify)

What was your gender at birthMaleFemaleOther (please specify)

If other please explain

Country of Citizenship

Ethnicity/Race

Primary Language

Interpreter RequiredYesNo

Do you have childrenYesNo

If you have children, are you court-ordered to pay child supportYesNo

Do you currently have a Child Protection/Dept. Social Service workerYesNo

Name

Agency

Phone

Email Address

If yes, please explain

Are you in a safe placeYesNo

If no, please explain

Have you ever been trafficked or exploited (sex or labor)YesNo

If yes, please explain

Are you still in a potential trafficking situationYesNo

If yes, please explain

Please list all services you are currently receiving or have received in the past

C. MEDICAL

Do you smoke Cigarettes or Vape?YesNo

If yes, please describe your usage

Is there a possibility you might be pregnantYesNo

Do you have health insuranceYesNo

If yes, Company Name

Phone

Group #

ID #

Prescription #

Are you able to safely navigate stairs (both up and down) in a large 1+ story homeYesNo

Do you agree to have a physical exam by a physician approved by Innocence FeedYesNo

Do you agree to have a mental health consultation with a provider by Innocence FeedYesNo

Do you have any medical conditions you are being treated for by health care providerYesNo

Are you currently taking any medications including over the counterYesNo

If yes, please list all medications, dosage, and frequency/time or day taken

Date Prescribed

Medication

Dosage

When taken

D. Substance Abuse

Have you ever used any substances (i.e. drugs or alcohol) in exessYesNo

If yes, please provide the following information

Type

Start date

Last use amount

Frequency

Treatment (Provide site, admission & discharge dates)

Have you ever used any substances in the last 30 daysYesNo

E. PSYCHIATRIC HISTORY

Have you been diagnosed with mental health conditionYesNo

If yes, please indicate

Have you ever been hospitalised or treated for mental health issuesYesNo

If yes, please indicate where and when

Have you ever attempted suicide or self-harmedYesNo

If yes, please indicate where and when

Do you have any eating disorderYesNo

If so, what disorder(s)

F. LEGAL

Have you ever been convicted of a crimeYesNo

If so, where

If yes, please specify each conviction, the date and any facts that might be relevant

Have you ever been convicted of a crime in a jurisdiction other than Douglas Country, NEYesNo

If yes, please specify each conviction, the date and any facts that might be relevant

Do you have any pending chargesYesNo

If yes, please explain

Do you have any upcoming court datesYesNo

If yes, when and where

Are there any current or pending conditions placed upon you by the courtYesNo

If yes, please describe in detail or attach a copy of the court order

Are you presently on parole/probationYesNo

If so, Name or Probation/Parole officer and contact information

Recovery Process

Share your reasons for seeking admission to Innocence Freed's residential program

Describe what you believe necessary for making lasting changes in your life

Do you think there is anything that may inhibit you living Innocence Freed's communityYesNo

If yes, please identify

H. TRANSPORTATION

Do you currently have means of transportation to Innocence Freed residential homeYesNo

STATEMENT OF AGREEMENT AND CONSENT

Please checkIf my application is approved, I am willing to sign Consent/Release forms for Medication Information, Criminal Records, Psychological Information, and Confidential Information to appropriate staff.If my application is approved, I am willing to submit to Random Drug Testing.I understand the program at Innocence Freed is centered on a meaningful relationship God and is foundationally faith-based.I understand that the Residential program is a 100% sober living environment, no narcotics, no unauthorized prescriptions or OTC such as Krathom.If I am a smoker, I understand I will be encouraged to be nicotine free at time of Graduation from the program.I commit to addressing any other life-controlling behaviors that I might have.Icertifythatallinformationhereisaccurateandtruetothebestofmyknowledge. Iunderstandthat any false or incomplete information may result in the disqualification of my application and, if discovered after I am accepted into the program, may be grounds for immediate termination.

Prospective Resident Signature

Date

Staff Signature

Date