Human Trafficking Survivor Intake Form
Date of Intake
Intake Staff Name
Survivor Information
Full Name
Age
Date of Birth
Gender
Nationality
Primary Language Spoken
Contact Information
Current Address or Location
Trafficking Experience
Type of Trafficking (e.g., Labor, Sex, etc.)
Estimated Duration of Trafficking
Location(s) Where Trafficking Occurred
How did you leave the trafficking situation?
Support Needs
Medical Needs
Psychological/Emotional Support Needs
Legal Needs
Current Safety Concerns
Additional Notes