Five14 Revolution Prescreening and Survivor Intake Form

Five14 Revolution Hotline Prescreen and Intake Form
PRESCREENING
Name*
Date

MonthDayYear
Date
Contact #
How did you hear about us?
Are you on Medication(s)?:

YESNO
Are you on maintenance medication (MAT)? IF yes, please list below:*
Mental Health Diagnoses*
Times incarcerated in the last 12 months:
Charges/Convictions
Have you exchanged sexual favors for money, drugs, food, shelter, or basic needs in the past?*

YESNO
If YES, how long ago?
If YES, please explain:
DO NOT COMPLETE THE REST OF THIS FORM IF THE ANSWER IS NO
SURVIVOR INTAKE
Address:*
DOB/ Age:*
SSN*
Gender:
RACE:

WHITEBLACKHISPANICASIANOther
Have you ever worked for someone in the commercial sex industry: (escort service, massage parlor, pimp, boyfriend)?

YESNO
If YES, please explain:
Are you safe in your current living situation?

YESNO
Are you interested or in need of emergency shelter?

YESNO
If you are interested in housing, please read and understand the following:
1. Must be able to climb stairs and be able to climb to a top bunk
2. Cannot have violent convictions (less than 1Oyrs), sex offenses or trafficking convictions
3. Cannot have a life-threatening allergy or seizure disorder
4. Personal phones are not allowed at all facilities
5. Free time may not be available at all programs for the first 2 weeks
6. Must agree to drug test, pat search, search of property, breathalyzer, etc..
7. Smoking may not be allowed or allowed on a restricted basis at some facilities
8. Must agree to sign a ROI for referrals to RHA, IFS or similar for mental health evaluations
Do you have a substance abuse disorder?

YESNO
If YES, please explain:
*Any person identified as having substances in their system at intake to the shelter requires the approval of the CADC or Mobile Crisis to stay at the shelter. (The only exception is when marijuana is the ONLY substance).
Do you have any mental health concerns/ diagnoses?

YESNO
Are you experiencing any delusions or hallucinations?

YESNO
Do you have any medical concerns?

YESNO
If yes, please explain
Do you have a history of seizures?

YESNO
If yes, please explain
Are you currently taking any medications?*

YESNO
If YES, please list:
*If there are medications that are not allowed at the shelter, this may result in ineligibility if unwilling or unable to change medications.
Please list any other recovery houses (if any) where you have previously lived in this area. Were you asked to leave? If so, please state the reason:
Needs Assessment (please select all services that you are in need of)

Emergency ShelterOutreach CenterSubstance Abuse CounselingMental Health CounselingRental AssistanceResidential FacilityFoodClothingMedical/ Dental ServicesDetox
What other forms of support are you currently receiving?
Restoration House Resident Requirements
- Client must be 18 years or older
- Client must have a history of sex trafficking or commercial sexual exploitation. We are unable to consider applicants who are:
  1. Using methadone/buprenorphine, or dolophine/suboxone (weak opioids) as opiate addiction treatment.
  2. Non-ambulatory or unable to manage self-care.
  3. A threat to herself or others; have assault or arson charges.
  4. On the sex offender's registry.
  5. Have an outstanding criminal charge/trying to escape a warrant.
  6. In a non-marital relationship that she expects to continue while in our program. (*We take very seriously the need for residents to refrain from relationships during the first 12 months of sobriety as suggested by na/aa.)
  7. Taking medications on our prohibited medications list (available upon request).
Important Notes:
- We are a no cost 120 day program. At 120 days, Fivel4 will work to place survivor in a long term residential program.
- We are a non-smoking facility/ nicotine patches/gun will be provided at no charge.
- Residents can use a landline to contact a parent(s) for the 1st 120 days.
- We are a restorative care PROGRAM with specific activities, schedules, and goals.
- We are "voluntary stay," but not a halfway house where she can come and go as she pleases.
- She will be expected to participate in therapeutic groups and individual counseling.
- Over time she can earn privileges, but they will not be immediate.
- She will be living with other survivors, sharing in the work and the dynamics of the household. Getting along with others is part of the program as we are rooted in relationship.
"Our hope for all survivors entering our program is that you will find a safe place of rest during these 120 days and that you will be able to build a firm foundation that transitions seamlessly into the rest of your journey."

Welcome to:
Five 14 Revolution Client Release of Information and Background Check

*All applicants are required to submit to a background check in order to determine eligibility for assistance from 514 Revolution. The following questions reflect those which are asked in our office upon performing an intake in person. If you would prefer to sign the background check form in person, you can make an appointment by calling our hotline at (910) 506-8514.*
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
I authorize Five14 Revolution to release/ and or obtain information from/to the following entity -VICTIG Background Checks- pertaining to my (MUST choose background check, but may choose any other that apply):

Pregnancy Test Result/ notesHousing StatusFinancial Status/ recordsLegal status/ purposesMaterial NeedsAssessment and Progress notesLabs/ other diagnostic testsSubstance use disorder recordsTreatment plans and reviewsMental Health RecordsBackground CheckOther
Client SSN:
Client Initials:
*By initialing on this line, you fully understand the terms of this release and waiver*
Client's Printed Name:
Client's Signature:

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Date:

MonthDayYear
Date
Should be Empty:

PRESCREENING

DO NOT COMPLETE THE REST OF THIS FORM IF THE ANSWER IS NO

SURVIVOR INTAKE

Five 14 Revolution Client Release of Information and Background Check