Form

Please answer the following questions in order to assist the Safe House Project Certification team in determining your certification needs.

Point of Contact First name*

Point of Contact Last name*

Point of Contact Phone number*

Point of Contact Email*

Program Name*

Is your program currently open and available to serve serve survivors in a residential setting?*

Yes

Program Type*

Healthcare Organization

Mental Health Treatment Facility

Eating Disorder Recovery

Addiction Treatment Facility (In-Patient)

Therapeutic Boarding School

Sober Living Housing

Domestic Violence

Sex Trafficking Specific Programming

Labor Trafficking Specific Programming

Aging Out of Foster Care

Refugee/Undocumented Immigrants

Post Jail/Prison Specific Program

General Trauma Recovery

Pregnancy Help Org

Housing Assistance (housing nav, section 8 vouchers, rent assistance etc.)

Non-gov Security/Extraction

What is the focus of your program?*

Drop In Center

Emergency - Focuses on Crisis Stabilization

Long Term - Programming to Process Trauma/Trafficking Experience

Transitional - Focuses on building new life, job, community

Independent Living - Focuses on living independently

Severe Weather Shelter

What ages do you serve?*

Adults

Minors in Foster Care

Minors not in foster care but charges fees

How many separate buildings do your residential programs operate in?*

How many survivors total can you serve at once time across all your programs?*

How many survivors does your program serve in a year?*

What is your organization's overall annual operating costs?*

Including staff salaries

What state(s) do you operate in?*

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia (DC)

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Virgin Islands

Washington

West Virginia

Wisconsin

Wyoming