The Lampstand Wraparound Services Inquiry
Please Fill this out to the best of your abilities. Please take your time, We understand that some of the questions may be hard to answer/ or too much to write. If you are unable to answer questions leave them blank and we can come back to it.
Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Where are you currently living?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Languages Spoken
Are you a survivor of Trafficking or exploitation? If any of the things listed happened to you please click yes -Pressured or forced to perform sexual acts in exchange for something you needed or wanted (e.g. money, food, shelter, protection etc.) -Being paid (or someone else being paid) for you performing sexual acts. -Worked in places where you were expected to perform sexual acts as part of your job. -Someone taking photos or videos of you in sexual situations without your consent for profit. -Forced or pressured by family to perform sexual acts for rent, money, drugs, or other benefits. -Made to feel like you had no choice but to perform sexual acts with people for money/resources because someone threatened you or someone you care about. -Not allowed to keep any of the money you made from performing sexual acts.-Had to perform sexual acts with people to pay off a debt or because you were told you owed someone. -Forced or pressured into commercial sex acts by a gang or criminal organization -Forced to work long hours or under abusive conditions without proper compensation (Labor Trafficking). -Identified as at risk or vulnerable due to age or other circumstances. -Physical, emotional, or sexual abuse from a partner or family member (domestic violence/no compensation exchanged). -Been a victim of sexual assault or violence.
Yes
No
No sure
Other
Please provide a quick description of what you need and your current situation.
What are some of your current needs?
Information and Referral
Personal Advocacy/Accompany
Emotional Support/Safety
Criminal/ Civil Justice Assistance
Education
Employment
Life Skills
Food/ Clothing/ Hygiene products
Identification Documents
Social Service
Chemical Dependency Services
Mental Health Services/ Counseling
Housing
Other
Who and What is most important to you?
What do you hope to gain from Wraparound Service?
Please share any life experiences you feel would be helpful for us to know to best help you right now. (pregnancy, disabilities, illness, or special circumstances)
What are some personal goals you would like to accomplish?
Submit
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