Form

This form is for survivors and advocates seeking Safe House Placement. Filling out this form will help streamline the referral process. However, if you do not have the necessary information or are overwhelmed by the form, you can fill out this simple call-back request form. Once you submit either form, we will call you as soon as possible.

Submissions are monitored from 7 AM-7 PM EST, and answered in the order in which they are received. If you are seeking immediate assistance, please call 507.769.0819 and select option 1.

Who is filling out this form?*

Full Legal Name of Survivor*

Is the person seeking services a survivor of sex trafficking?*

Is the survivor seeking residential placement in a short-term shelter or long-term trafficking recovery program?*

Survivor's Initials*

Survivor's Date of Birth

Month/Day/Year

What is the age of the survivor?*

Survivor's Gender*

What are the survivor's preferred pronouns?

Current Location of Survivor*

If Applicable, Date the Survivor Exited Trafficking Situation

Month/Day/Year

Please select the level of urgency for timeline of placement.

Check if the survivor is willing to go out of state.

Are there any locations where the survivor cannot go?*

Survivor has pending legal issues/court hearings they need to attend in their state

Survivor cannot go to/through a particular state

Please provide a brief description of the need and current circumstances of the survivor.*

Which of these options best describes the level of staff supervision you believe you need?*

In-Patient Supervision - Medical/Mental Specialized Health

High - 24/7 on Site Supervision

Moderate - Staff on site during the day/no overnight staff

Low - Weekly Check-Ins/No on-site staff

Length and Type of Program Needed (choose ONE)*

Please only choose ONE program

Emergency - up to 90 days

Long Term - Typically 1 to 2 years

Transitional/Independent Living - Must currently be in/completed a recovery program

List any programs the survivor has previously participated in.

Are you willing to go to a faith-based program?*

Does the survivor speak and understand English fluently?*

Citizenship*

Does the survivor have a valid ID card?

Yes

If applicable, what is the date of last drug use?

Month/Day/Year

Does the survivor smoke or vape nicotine products?

Yes - Cigarettes

Yes - Vapes

Check if the survivor needs immediate mental health stabilization.

Survivor's Physical Status*

Explain any specialized health needs (if applicable).

Is the survivor able to participate in chores, employment, community service, or physical exercise?

Yes

Does the Survivor have a history of violent or sexual crime offenses?

Yes

Relevant Documents

Additional documents

How did you find out about us?*