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Bakhita Mountain Home Referral Form
Please fill out this form for any potential referrals into our housing program for adult survivors of Human Trafficking. Please review all Eligibility Criteria before continuing. Email Jason at jason@bakhitamountainhome.org
if you have any initial questions.
Eligibility Criteria
Women over the age of 18
Who:
Have started recovery work and/or trauma healing and ready to move forward
Have successfully completed initial detoxification as applicable
Have a desire to live in a sober community environment and able with necessary accommodations to live within the residence
Are not the sole custodian of a minor child
Are not currently pregnant
Have experienced trauma through sexual exploitation and or sex trafficking
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* Indicates required question
Email
*
Your email
Referral Source Email
*
Your answer
Does the applicant meet all eligibility criteria? (Listed above)
*
Yes
No
Other:
Applicant Name
*
Your answer
Applicant Contact Information (phone and email)
*
Your answer
Referral agency ( staff's name, agency, title)
*
Your answer
Referral agency contact (phone and email)
*
Your answer
Why do you feel the applicant would be a good fit for BMH? Speak to the individuals readiness, and desire to continue to heal.
*
Your answer
What type of treatment has the applicant been in? If unknown please reach out to perspective resident for clarification.
*
Your answer
What current needs does the applicant have? (medical, dental, mental health, physical)
*
Your answer
Do you have a history with addiction?
*
Yes
No
Please include details of the following if applicable:
Current length of sobriety, drug of choice, treatment
Your answer
What is the applicant's current living situation?
*
Group/Recovery Home
Shelter/Short-term/Emergency Housing
Treatment Program
Shared living arrangements ( living with companion, family or friends)
Independent Living
Other:
When is the applicant looking to move? When would they be ready and how long are they able to wait to move?
*
Your answer
Why is independent living appropriate for the applicant at this time? Explain the individuals readiness for this type of programming.
*
Your answer
Any additional information that is helpful for BMH to know?
Your answer
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