Human Trafficking Victim Immigrant Intake Template
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Non-binary
Other
Country of Origin
Language Spoken
Interpreter Needed
Yes
No
Contact Phone
Email Address
Immigration Information
Current Immigration Status
Date of Entry to Country
Method of Entry
Visa
Asylum
Other
Trafficking Experience
Brief Description of Trafficking Situation
Type of Trafficking
Labor
Sex
Both
Other
Date Trafficking Began
Date Trafficking Ended
Current Living Situation
Immediate Safety Concerns
Support & Legal Information
Receiving Legal Assistance?
Yes
No
Receiving Social Services?
Yes
No
Other Notes