Human Trafficking Victim Intake QuestionnaireThank you for trusting us. This questionnaire is confidential and voluntary. Please answer as honestly as you feel comfortable. You can skip any questions if you feel uncomfortable or unsafe answering them.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. gender or phone 1. What is your full name (or the name you prefer to use)? *2. How old are you?3. What is your gender identity?4. What languages do you speak or understand?5. Do you have any children or dependents? If yes, how many, and what are their ages?6. Are you currently in a safe place? *7. Do you have access to food, shelter, or medical care right now? *8. Do you feel threatened or in danger at the moment? *9. Do you have any immediate medical concerns or injuries we should know about? *10. Do you need any specific accommodations, such as a wheelchair or interpreter?11. Where are you currently living (e.g., with family, friends, employer, shelter)?12. Who brought you to your current location, or how did you arrive here?13. Are you currently working? If yes, what type of work are you doing?14. How were you recruited or offered the job?15. Are you allowed to leave your workplace or residence freely? *16. Do you receive payment for your work? *17. Do you owe money to anyone for travel, housing, or other expenses?18. Has anyone taken your money, documents, or belongings without your permission? *19. Do you feel free to make your own decisions about your life, work, or relationships?20. Has anyone ever threatened you or your loved ones to make you do something? *21. Has anyone controlled or monitored your movements, communication, or activities? *22. Have you experienced physical, emotional, or sexual abuse? *23. Do you have access to any support systems, such as family or friends?24. How would you describe your mental and emotional state at this time? *25. Is there anything else you want us to know or talk about?26. What is the best phone number we can call or text you on? *27. What is the best email address we can reach you on? *Submit
