Intake Form | Scarlet Rope Project

PLEASE REVIEW THE FOLLOWING BASIC ADMISSION CRITERIA:

*Women over 18 who are survivors of sex trafficking, with addiction as a co-occurring disorder.

*Able to perform basic activities, such as eating, bathing, movement

* Willing to commit to a 18-24 month, faith based program for treatment and healing (no intimate relationships are allowed for residents)

*Able to live in community and maintain appropriate behavior.

*Willing to submit to and pass regular and random drug testing

*Not on the sex offender registry

DO YOU MEET THE ABOVE CRITERIA? IF YES, COMPLETE THE REMAINDER OF THE QUESTIONS.

First name

Last name

Phone

Best way and time to reach you?

List Medical Conditions and Diagnosis

List Mental Health Conditions and Diagnosis

List all current medicatons (Name, Dosage, when taken). (Suboxone is not allowed)

What are you looking for in a Program? What do you need to succeed?

Birthday

What City and State are you currently in?

How did you hear about our program?

Thanks for submitting!