Let's Get Started | Pathways Home

If You Would Like To Join Our Program, Let's Get Started

Please complete our preliminary intake form, and we will be in touch very soon. It usually takes at least 3 business days. If you are in need of shelter please indicate that on this application to speed our response time.

Date *

Name *

Legal name if different from the name you provided *

Do you identify as a victim/survivor of human trafficking? *

How can we contact you? Include phone number, email, or mailing address. *

Are you an American Citizen? *

If you are not an American Citizen, what is your country of origin? *

What is your Date of Birth? *

Are you at least 19 years old? *

Are you in danger or do you have immediate safety needs? *

Do you need medical attention? *

Do you have basic needs, such as clothing, food, shelter, medication, toiletries, transportation, other? *

Basic disclosure of trafficking experience: just give a brief description of your experience. We will talk more about this at your intake if you are accepted into our program. *

How were you referred to the shelter? [examples: website / social service organization / police / church, etc.] *

Have you ever been in another shelter *

If you have been in another shelter, what is the name and location of it? *

Do you have any suicidal thoughts or ideation or any active self-harm risk? *

Do you have any forms of identification, such as a passport, driver's license, state ID, visa? *

Are there any children dependent upon you? *

If you have dependent children, please list their gender along with the age of each. *

What is the highest level of education you completed? *

What is/are your current sources of income? *

List any of the following you may need help with: job training, education, family reunification, benefits, employment, vocational training, housing. *