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How did you hear about the SAFE Center?

Name

First

Last

Are you Under the age of 18?

Yes

No

Date of Birth

Number Phone

Is this a safe number to contact you?

Yes

No

What is a good time for us to call you?

Can we leave a message on this number?

Yes

No

Email

Gender Identity

Preferred Pronouns

County of Residence

Primary Language

We want to understand what has happened to you, so that we can better help you. Please read and answer the following questions.

It is not uncommon for people to stay in work situations that are risky or even dangerous, simply because they have no other options. Have you ever worked, or done other things, in a place that made you feel scared or unsafe?

Yes

No

Sometimes people are prevented from leaving an unfair or unsafe work situation by their employers. Have you ever been afraid to leave or quit a work situation due to fears of violence or threats of harm to yourself or your family?

Yes

No

Sometimes people who are homeless or who have difficulties with their families have very few options to survive or fulfill their basic needs, such as food and shelter. Have you ever received anything in exchange for sex (e.g. a place to stay, gifts, or food)?

Yes

No

Sometimes employers don’t want people to know about the kind of work they have young employees doing. To protect themselves, they ask their employees to lie about the kind of work they are involved in. Have you ever worked for someone who asked you to lie while speaking to others about the work you do?

Yes

No

11. In a few sentences can you describe what’s happened to you, so that we can determine how we can best support you:

What kind of help or services you are seeking? (Select All that Apply)

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