Incident and Assistance Form
We appreciate you wanting to share with us. You are free to skip any question or stop at any time. Our goal is to understand your experience so we can better support you. You may share as much or as little detail as you feel comfortable providing.
Your Name
First Name
Last Name
City/State
Can you share how you first became involved in prostitution or exploitation?
Were there circumstances that led you into this situation (financial hardship, coercion, trafficking, homelessness, abuse, addiction, etc.)?
How old were you when this began?
Did anyone pressure, threaten, or force you into it?
Do you need medical care, shelter, legal help, counseling, or transportation?
Would you like assistance connecting with support services?
Do you consent to this information being documented for support/services?
Yes
No
Submit Form
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