Brief Intake Screening

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Please complete this form to determine eligibility for services. Information will be used to connect you to services.

All personal information will only be used for this purpose.

Email *

If you are experiencing an emergency, please contact one of the following numbers. For ongoing services, not crisis needs, complete the rest of the form.

Do you identify as a Survivor/Lived Experience Expert of Sex Trafficking? *

Yes

Not sure

Length of time out of exploitation

currently experiencing/not out of exploitation (referral for programming)

under 1 year

1-2 years

3-5 years

5+ years

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This form was created inside of Restoring Ivy Collective, Inc. Report Abuse

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