National Trafficking Sheltered Alliance Form
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Today's Date *
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Do NOT put identifying information on this application. Your candidate will only be identified in this Network by the person's 3 initials and age. For example, AGW21. Please provide this identifier below.
Screening Guide for Human Trafficking and Domestic Sex Trafficking
This is a guide to suggest if an individual may be a victim of domestic human
trafficking. Affirmative responses do not necessarily conclude that the individual is a
victim. Multiple affirmative responses should be investigated by law enforcement. It is
advised that the interviewer give the interviewee full control of his/her responses and
not probe unduly. You may invite the interviewee to elaborate on any of the questions,
if appropriate. (Adapted from a previous screening tool created by NYCTAP)
Has anyone ever taken and kept your identification, or provided you with alternative identification that was false? *
Have you ever worked without getting the payment expected? *
Have you ever been punished (beaten, deprived of basic needs, isolated, etc.) for not making a certain amount of money? *
Has anyone you ever worked for or lived with been responsible for your food (whether or not you ate, how much, what food, etc.)? *
Have you ever lived in or worked at a place where the doors/windows were locked and you were restricted from leaving when you wanted? *
Has anyone you ever worked for or lived with denied your contact with family, friends or others? *
Has anyone you ever worked for or lived with taken/kept money that was yours in exchange for food, transportation, rent, clothing, beauty treatments, etc.? *
Have you ever lived with or worked for someone where you felt that if you wanted to leave that situation, you—or someone you care about—would be in danger? *
Have you ever received anything of value (money, housing, food, gifts, drugs) in exchange for any activity involving sexual contact? *
Was this work any of the following: escort service, strip club dancer, massage parlor, phone sex—or anything similar? *
Alliance Referral System Form
Please email the completed form to referral@shelteredalliance.org.
By completing this application, you are agreeing to allow the National Trafficking Sheltered Alliance
to circulate this application amongst its member agencies within 24 hours for the express purpose of
facilitating a residential placement for your Candidate. This form must be filled out completely before
submission. ALL INFORMATION WILL BE KEPT CONFIDENTIAL within the Alliance network. You will
be contacted directly by any agency that has availability and is willing to consider your Candidate.
ARS will not replace the assessment process of individual agencies; we are a facilitator only.
Referrer Information
Referrer Name *
Referrer Agency Name (If applicable) *
What is your relationship to the candidate? *
City & State *
Referrer Contact Email *
Referrer Contact Phone Number *
How long have you known the Candidate? (include months, weeks, and days) *
Candidate Information
The candidate is currently residing in (include City & State) *
Gender *
Please indicate racial/ethnic background (this is optional, in case the candidate qualifies for specific minority-serving agencies) *
Are you, or could be pregnant?   *
Does the Candidate need a program that accepts dependent child(ren)? If yes, list how many children and their ages. *
By what date does the candidate need placement? *
What type of program is the candidate seeking? *
What sleeping arrangements make you most comfortable? (Check all that apply)  *
Required
Is the Candidate a high flight risk? *
Level of Supervision Recommended: *
How would you like faith to be incorporated into the program, if at all? *
Is the candidate able and willing to relocate out of State? *
Does the candidate have any preferences or limitations on where in the United States she should be placed? Please explain *
Does the candidate require services in a specific language? If so, please specify: *
What is the nature of the trafficking? *
Required
How was the trafficking activity verified? *
How recent was the candidate trafficked/sexually exploited? (include months, weeks, and days) *
Has this Candidate previously (or currently) been in a trafficking shelter program? If yes, which program *
Will your agency/the candidate fund the cost of relocation? *
Does the candidate have any means to pay for placement (insurance, family support, disability, etc)? Explain *
What else is pertinent to the placement of this Candidate? *
Legal
Candidate is a(n) *
If under the age of 18, please specify: *
Please select all that apply: *
Required
Is there an open or pending case against the trafficker? *
Is the trafficker(s) in custody? *
Is the Candidate currently incarcerated? If yes, date of release? *
Is (or will) the Candidate be on parole/probation? *
Please describe any outstanding warrants or legal obligations that will affect the candidate ability to travel outside the state: *
Health Information
Does the Candidate have any immediate health concerns or physical limitations? If yes, list health concerns *
Does the candidate need accommodations for any physical disabilities? If yes, please describe: *
Is the Candidate actively self-injuring? *
Is the Candidate a suicide risk? *
Does the Candidate have severe psychiatric issues? If yes, list psychiatric issues *
Is the Candidate on prescribed pharmacology for mental illness? If yes, list prescribed pharmacology *
Has the candidate recently used illegal substances? If yes, approximately how long ago? *
Has the candidate ever been in rehab for drug or alcohol abuse recovery? If yes, how many times? *
Is the candidate in need of addiction recovery services? *
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