Referral Agency Point of Contact *

First Name

Last Name

Relationship to Applicant *

Law Enforcement/Task Force

Legal Counsel/Court Official

Social Worker/Case Manager

Safe House or Trafficking Shelter

Anti-Trafficking Agency

Friend/Family Member

Self

Applicant Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Our residential home is equipped for biological female residents only at this time.

Male

Female

Other

Applicant is: *

Our focus is domestic victims at this time.

U.S. Citizen

Legal Foreign National

Undocumented Foreign National

Do you believe the applicant is a victim of commercial sexual exploitation by means of force, fraud, or coercion? *

Yes

No

Does the applicant have any outstanding warrants or legal obligations? *

Yes

No

Is the trafficker in custody? *

Yes

No

N/A

Is there an open or pending case against the trafficker? *

Yes

No

N/A

Is the applicant currently incarcerated? *

Our program is not an alternative to incarceration. Residents will not be accepted if court mandated - only voluntary applicants are considered.

Yes

No

If yes, please provide a release date.

MM

DD

YYYY

Is (or will) the applicant be on probation/parole? *

Yes

No

Is the applicant a flight risk? *

Yes

No

Is there a chance the applicant could be pregnant? *

Our residential home is not equipped for pregnant residents at this time.

Yes

No

Is the the applicant actively self harming? *

Yes

No

Is the applicant a suicide risk? *

Yes

No

Does the applicant have at least 30 days sobriety/clean time? *

Yes

No

Is the applicant on prescribed pharmacology? *

We do not allow stimulants of any kind, including for the purpose of ADHD management. We also have guidelines on prescribed sleep aids, medications for seizure disorders, and anti-psychotic medications. We will require a complete list of medications the applicant is currently taking and the purpose.

Yes

No

Does the applicant have any severe psychiatric issues? *

We are not equipped for residents suffering from Schizophrenia or Schizoaffective Disorder. We do not have medical personnel on staff at this time.

Yes

No

Does the applicant have any immediate health concerns or physical limitations? *

Our program is robust in nature and requires physical participation. All bedrooms are located on the second floor with no elevator access. Residents are moving up and down the stairs frequently throughout the day. We do not have medical personnel on staff at this time.

Yes

No

Does the applicant need a program that accepts dependent children? *

We are not equipped for residents with children at this time.

Yes

No

Does the applicant know that we are a faith-based organization, but offers both faith-based and secular-based programming? *

We do not require our residents to be of the Christian faith, but residents are exposed to Christian symbols such as crosses hanging on the wall and conversations that may include the name of Jesus. We do not allow witchcraft, wiccan, or satanic practices in the program.

Yes

No

Has the applicant previously (or currently) been in a trafficking shelter program? *

Yes

No

Have you presented the idea of Redeemed Ministries' Sparrow House to the applicant? *

Yes

No

Do you believe the applicant is receptive to a long-term residential program such as ours? *

Some individuals may prefer short-term programs or transitional programs. Our program residents are not allowed to have a cell phone for the first year they are in the safe house, and they have limited internet access. Residents are eligible to begin working outside of the program at approximately one year. Before that they become eligible to work in the organizations economic empowerment program once they have completed 2 full semesters of programming. They will earn money while in the economic empowerment program.

Yes

No