Referral Application

  • Restoration Program Application

    North Star Initiative

  • North Star Initiative
    Residential Program

    Admission Application

    Please note: We are not an emergency service. If you are in need of emergency placement, please contact 911 or the human trafficking hotline at 1(88) 373-7888.

    Program Restrictions
    Please know that North Star is resourced to provide services for a participant who meets the following criteria:

    • Is between the ages of 18-35 at the time of applying
    • Has been clean and sober at least 30 days (at the time of intake)
    • Does not have dependent children who require placement
    • Is ambulatory
    • Is biologically female
    • Is not prescribed methadone
    • Is able to self-manage

    If all of the above are true of the applicant, we look forward to learning more through this application.

    This form assists NSI staff in determining whether we are the best fit for an applicant to participate in our residential program. We ask that all information be completed in a concise, thorough manner. The application will be reviewed by the multi-disciplinary team before making any determination of acceptance into the program.

    Completion of this application assumes the participant consents to allow the Referring Agency to provide this information in consideration for her acceptance to the Restoration Program.  We do not discriminate based on the responses provided on this form.  Your candid, factual, and complete responses assist us in proceeding with the referral process.

    ALL INFORMATION WILL BE KEPT CONFIDENTIAL

  • Applicant Identification Information

  • Date of Birth*
     - -
  • English Fluency*
  • Gender*

  • Racial Category (check as many that apply): NOT REQUIRED

  •  -
  • Please check below the best way to contact you.*
  • Relationship to Applicant:*

  • If applicable:

  •  -
  • Is she willing to participate in a Christian program?*

  • Safety Assessment

  • Has she been verified as a victim of human trafficking? (either sexually exploited as a minor, or prostituted as an adult through the means of force, fraud, or coercion)*
  • How was the trafficking verified?*
  • What type of exploitation are you seeking recovery from? (check all that apply)*
  • Is her trafficker(s) still a threat to her?*
  • Is she still in contact with her trafficker?*
  • Is there an open or pending case against her trafficker?*
  • Was she trafficked in any of these states? (Check all that apply)*
  • Is she currently (or recently) affiliated with a gang?*
  • Is her family unsafe or unhealthy?*
  • Does she have a history of violence?*
  • Is she in a significant debt situation that poses a threat?*
  • Is she a high flight risk?*

  • Legal Information (if applicable)

  • Is the applicant "committed" to the state?*
  • Is the applicant currently on probation?*
  • Does the applicant have a warrant?*

  • If "Yes" to any of the above, name of the court service worker or probation officer and list Offense:

  • Other Information:

  • Is she court ordered for placement?*
  • Does she have an open case against her trafficker?*
  • Would she be considered under house arrest?*

  • Family Information

  • Parent 1

  •  -
  •  -
  • Date of Birth:
     - -

  • Parent 2

  •  -
  •  -
  • Date of Birth:
     - -

  • Applicant's Children

  • Does she have children?*

  • If yes....

  • Date of birth
     - -
  • Date of birth
     - -
  • Date of birth:
     - -
  • Date of birth:
     - -

  • Social Services Information

  • Has the applicant previously (or currently) been in a trafficking shelter program?*

  • List the three most recent residences the applicant has had:

  • List any agencies that have been involved in serving the applicant during the last five years:

  • Rows

  • Medical Information

  • Is the applicant pregnant?*
  • (If she is pregnant) Has she been to a pregnancy center or started prenatal care?*
  • Does the applicant have valid medical insurance?*
  • Does the applicant have any health problems? If "yes", explain below:*
  • Is the applicant currently taking medication?*
  • Does the applicant have any known allergies?*
  • Does the applicant have a mental health diagnosis?*
  • Is the applicant currently taking medication for a mental health diagnosis?*
  • Is the applicant currently experiencing any of the following (Responses to this question do not exclude you from potential acceptance):*
  • Does the applicant have any history of drug use?*
  • Has the applicant been through a rehab or detox program?*
  • Does the applicant require accommodations for any of the following:*

  • Education Information:

  • Has the applicant been in special education classes?*
  • Does the applicant have any learning challenges?*

  • Additional Information

  •  Thank you for applying!

    If you need assistance with any part of this application, contact myoung@northstarinitiative.org or 717-268-9124 

     

    You can anticipate a response from our team within 24 hours on the status of your applicant upon submission.

     

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