514 Revolution Survivor Intake Form

PRESCREENING
Full Name (First, Middle, and Last)
Today's Date

MonthDayYear
Date
Contact #:
How did you hear about us?
Are you on Maintenance (MAT)?
Times incarcerated in the last 12 months:
What were your charges/ convictions?
Have you exchanged sexual favors for money, drugs, food, shelter, or basic needs in the past?

YESNO
If so, how long ago?
If so please explain in some detail:
DO NOT COMPLETE THE REST OF THIS FORM IF YOU ANSWERED NO TO THE LAST QUESTION.
INTAKE
Address
DOB / AGE:
Social Security Number:
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
If you are NOT safe in your current living situation, are you interested in emergency shelter?

YESNO
Do you have a history of any of the following? (please select all that apply):

Alcohol AbuseAttempted SuicideBoyfriend/ PimpChildhood Physical AbuseChildhood Sexual AbuseDivorce (Parents)Divorce (Personal)Domestic ViolenceDrugsFoster CareHomelessnessIncestJuvenile RunawayLost Custody of ChildrenMajor Depressive DisorderMental IllnessOn MaintenanceOnline EscortPrison RehabPsych MedsPTSDWorked in Strip Club
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
Any person identified as having mental health concerns may be asked to speak to a representative from Mobile Crisis or RHA for an assessment.
Are you experiencing any delusions or hallucinations?

YESNO
If yes, you must agree to speak to a representative from Mobile Crisis or RHA.
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.
Are you affiliated with any gangs?

YESNO
What other recovery houses (if any) have you lived in this area? Were you asked to leave? If so, please state the reason:
Needs Assessment (Please check all that apply)"

Emergency ShelterOutreach CenterSubstance Abuse CounselingTrauma-Informed TherapyRental Assistance *Please note that rental assistance is not guaranteed to any person(s). It is only available for approved recovery programs and will be given on a case by case basis if a client meets the necessary requirements.*Residential FacilityFoodClothingGroup Trauma TherapyDetox
Do you receive: SSI, Disability, Food Stamps, or Medicaid? If so, please list all that apply and the amount of each, if applicable.
Restoration House Requirements
- Be age 18 or older.
- Have a history of sex trafficking or commercial sexual exploitation.
- We are unable to consider applicants who are:
  - Using methadone/buprenorphine, or dolophine/suboxone (weak opioids) as opiate addiction treatment.
  - Non-ambulatory or unable to manage self-care.
  - A threat to herself or others; have assault or arson charges
  - On the sex offender's registry
  - Have an outstanding criminal charge/trying to escape a warrant
  - 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
  - Taking medications on our prohibited medications list (available upon request)
-We are a no cost 120-day program. At 120 days, Five14 will work to place survivor in a long-term residential program.

-We are a non-smoking facility. Nicotine patches/gum 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:
Five14 Revolution Client Release of Information and Background Check
I Full Name* , DOB date of birth *, a client of Five14 Revolution authorize Five14 Revolution personnel to release and/or obtain information from/ to the following entity: _________VICTIG /other entity(s) pertaining to my:
Please choose all that apply:*

Pregnancy test results/notesHousing statusFinancial status/ recordsLegal status/ purposesMaterial needsAssessment and progress notesLabs/ other diagnostic testsSubstance use disorder recordsTreatment plans and reviewsMental health recordsBackground Check*Other
Client SSN*
This authorization will expire in one year from the date signed unless revoked at an earlier date.
I may revoke this consent at any time by written notification to Fivel4 Revolution. I understand that the revocation has no effect on actions taken prior to the date of revocation. I approve the exchange of information and understand that confidentiality cannot be assured when information is faxed. My initials below signify acceptance of the risk that confidentiality may be breached when information is faxed. I understand that the information provided can be given either written or verbal. I understand that only the information specified below may be disclosed and that the information is protected by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA Federal regulations prohibit you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or his/her parent or legal guardian unless otherwise permitted by such regulations. Pursuant to Public Law 93-579, the Privacy Act of 1974, I hereby request and authorize the above named agency or organization to release information on my behalf to Fivel4 Revolution. I understand that the information released may be sensitive or confidential in nature. This authorization is valid only if received within 60 days of being signed.
By Initialing on this line, you fully understand the terms of this release and waiver*
Client Printed Name
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PRESCREENING

DO NOT COMPLETE THE REST OF THIS FORM IF YOU ANSWERED NO TO THE LAST QUESTION.

INTAKE

Five14 Revolution Client Release of Information and Background Check