The Lifeboat Project Application Form
This form is for survivors and advocates seeking placement in our Compass Program (read more here). Filling out this form will help streamline the referral process. However, if you do not have the necessary information or prefer to speak with someone, please call our office at 407-310-8905. All information provided is held securely and confidentially; only authorized staff will have access to your information.

Calls and form requests are monitored Monday-Friday from 8:00AM-4:00PM, and are answered in the order which they are received. If this is an emergency, please call the National Human Trafficking Hotline at 888-373-7888 or call 911.
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Email *
Who is filling out this form? *
If the survivor is being referred by an agency, please write down the name of the agency, otherwise write N/A. *
Full Legal Name of Survivor *
Is the person seeking services a survivor of trafficking? *
Is the survivor seeking residential placement, or community services such as mental health counseling? *
Is the survivor willing to go out of state? *
What is the race of the survivor? *
Survivor's Age and Date of Birth (MM/DD/YYYY) *
Survivor's Legal Gender and Preferred Pronouns (she/her, he/him, they/them, etc.) *
Survivor's Current Address, City, State, Zip Code *
Survivor's Cell Phone Number *
Survivor's E-Mail *
Does the survivor have a driver's license? If yes, which state was the license issued in? *
Does the survivor have an ID? If yes, which state was the ID issued in? *
Does the survivor have a birth certificate? *
Does the survivor have access to their Social Security Card? *
Survivor's Current Legal Marital Status *
Does the survivor have a boyfriend/girlfriend/fiance? If yes, please state their name. *
Has the survivor had or currently have a substance use disorder? If yes, what is the date of the last illegal drug use? *
What is the survivor's drug(s) of preference? (Write N/A is this is not applicable).
If the survivor has a partner, have they had or currently have a substance use disorder? *
If the survivor has children, please write the following: Name(s), Date of Birth(s) (MM/DD/YYYY), Legal gender(s), and Present Living Situation/Caregiver(s). Please also write if the children have open DCF cases. (Write N/A if this is not applicable). *
If the survivor has children, please write the Father's Name and Phone Number as well as the Mother's Name and Phone Number. (Write N/A if this is not applicable). *
Survivor's Emergency Contact Information (Name, Phone Number, Relationship). *
Does the survivor have any pending criminal charges? If yes, what state? Please explain. *
Does the survivor have any known medical diseases or disorders? Any known mental health diseases/disorders? *
Please list any food, medication, or environmental allergies: *
Please write down all substances used by the survivor, how often they were used, and age of first use. (Write N/A if this is not applicable). *
What is the highest level of education completed by the survivor? *
What career/job would the survivor like to have in the future? *
What type of skills does the survivor have? *
How did you find out about The Lifeboat Project? *
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