Initial Safety & Exploitation Screening (For Adults 18+)
Answer the questions you’re comfortable with to help us understand your safety and support needs—skip anything you don’t want to answer.
Client Name
First Name
Last Name
Referral Source (ie self, organization, etc.)
Staff Member Completing Screening
First Name
Last Name
Immediate Safety
Do you feel safe right now?
Yes
No
Is anyone actively looking for you or trying to contact you against your wishes?
Yes
No
Unsure
Are you afraid that someone may hurt you or someone you care about?
Yes
No
Do you have a safe place to stay tonight?
Yes
No
Notes
Control & Coercion
Has anyone ever controlled where you go or who you talk to?
Yes
No
Has anyone ever taken your important documents?
Yes
No
Has anyone ever kept your money or paycheck?
Yes
No
Has anyone ever forced you to ask for permission before leaving?
Yes
No
Has anyone ever threatened you, your children, family, or pets?
Yes
No
Has anyone ever used physical violence against you?
Yes
No
Has anyone ever prevented you from getting medical care?
Yes
No
Notes
Human Trafficking Indicators
Has anyone ever pressured or forced you to exchange sex for money, drugs, housing, food, transportation, or protection?
Yes
No
Has anyone ever made money from your sexual activities?
Yes
No
Has anyone ever advertised or posted photos or videos of you online without your full consent?
Yes
No
Has anyone ever forced you to work without fair pay?
Yes
No
Has anyone ever forced you to keep working because of debt?
Yes
No
Has anyone ever lied to you about work, housing, or a relationship that resulted in exploitation?
Yes
No
Has anyone ever prevented you from leaving a job or situation?
Yes
No
Notes
Sexual Violence
Have you ever been forced or pressured into sexual activity you did not want?
Yes
No
Have you ever been sexually assaulted?
Yes
No
Have you ever been touched sexually without your consent?
Yes
No
Have you ever been forced to perform sexual acts to avoid punishment or receive basic needs?
Yes
No
Notes
Domestic Violence
Controls your finances?
Yes
No
Constantly monitors your phone or location?
Yes
No
Is physically violent?
Yes
No
Is emotionally abusive?
Yes
No
Threatens to take your children?
Yes
No
Has strangled or choked you?
Yes
No
Notes
Labor Exploitation
Have you ever worked long hours without being paid fairly?
Yes
No
Have you ever been unable to leave your workplace?
Yes
No
Have you ever been threatened if you quit?
Yes
No
Have you ever had your identification or immigration documents taken?
Yes
No
Have you ever been forced to live where you worked?
Yes
No
Notes
Children
Are your children safe?
Yes
No
Has anyone threatened your children?
Yes
No
Have your children witnessed violence?
Yes
No
Are you concerned someone may try to take your children?
Yes
No
Notes
Needs Assessment
What do you need most today?
Safe housing
Food
Medical care
Mental health support
Sexual assault advocacy
Domestic violence services
Legal assistance
Law enforcement assistance
Childcare
Clothing
Transportation
Substance use support
Other
If other, please specify
Notes
Final Screening Questions
Do you believe you may have experienced trafficking, exploitation, abuse, or violence?
Yes
No
Unsure
Has anyone ever made you do something you did not want to do in order to survive?
Yes
No
Has anyone ever profited from you while controlling or exploiting you?
Yes
No
Notes
Staff Use Only
Red Flags Observed
Appears fearful
Someone answers for client
Inconsistent story
Other
Red Flags Observed - Other (specify)
Screening Outcome
No indicators identified
Domestic Violence indicators
Sexual Assault indicators
Sex Trafficking indicators
Labor Trafficking indicators
Multiple victimization indicators
Immediate safety concern
Mandatory reporting required
Submit
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