Intake/Referral Form
In House Information and Eligibility: 
18+ years old
Cisgender women, trans women, Two Spirit people and gender expansive people are all eligible
Have been or are currently being sexually exploited and needing a place to seek healing
Have been involved or currently looking to exit voluntary sex work
This is a voluntary program
Due to mandate and licensing, those involved in our housing program must be sober
The house is unfortunately not wheelchair accessible
We support people in finding their voice and independence
We are not a treatment facility
We are not a shelter
We are not a Housing First program

Outreach Information and Eligibility:
Any age is eligible
Any gender is eligible
Have been or are currently being sexually exploited
Have been or are currently involved in voluntary sex work
Voluntary and generalist support services
You do not have to be sober to access services and support
This is not an in house program, but can provide transportation, visits, access to programming, etc.

Please note that throughout this form, when using the term "you" in the Personal Information section, we are referring to the person who is being referred to HRC for services. If you are a support worker filling out this form on behalf of someone, we are not referring to you, but the person you are supporting.

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Email *
Are you looking for In House or Outreach Support?  *
Referral Source *
Name of Person Referring *
If you are an organization or healthcare facility, where are you referring from? 
Personal Information
This next portion goes over personal details about the individual being referred. If you are self referring, please take your time and exit if you need to. If you are struggling to answer any questions, please reach out to dessal@hoperestoredcanada.org and she can assist you in completing the form. 
Legal Name *
Pronouns *
Alias/Preferred Name
Date of Birth *
Age *
Allergies? Please put "No" if no allergies. *
Current Location (city, facility, etc) *
What is the best way to contact you?  *
Please provide your contact information here. *
If you do not have personal contact information, please put your support worker, colleague, family or friend's name and contact information below.
Please select the option that best describes your experiences?  *
Do you use substances? *
If you answered yes, what are your substances of choice? 
When you are using, how often are using? 
Clear selection
When are you looking to move in? (this is just for housing needs)
Thanks for taking time to fill out these questions, they help us better understand how we can support you! Once we have received this referral, please allow 2 business days for contact from someone on our team.
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