EXIT Program Referral Form

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- Step 1 of 4

PERSONAL INFORMATION

Is it safe for you to talk?

Name *

First

Last

Date of Birth *

What is the best way for us to contact you? *

Phone
Email

Is it safe for us to leave a message for you? *

Your Phone Number

Your Email

Alternate Contact Name

Alternate Contact Phone Number

Date you first contacted RESET for services

EXIT PROGRAM ELIGIBILITY

RESET's mandate is to support women who have been sex trafficked or sexually exploited by providing programming and support through the EXIT Program. The EXIT Program is a voluntary program. RESET does not accept women who are specifically mandated to attend the EXIT Program. Eligibility criteria for the EXIT Program is as follows:

16 year of age or older
Female or persons identifying as transgender. Those undergoing gender reassignment procedures would also be considered
Being sexually exploited or at risk of sexual exploitation
Self-Referral
Desire for recovery, healing from exploitation and willingness to participate in the EXIT Program

Do you meet all of the above criteria? *

Check the boxes that apply to you

At risk of exploitation
Survival sex
Inside work (escorting, massage parlour)
Online work
Outside work (streets)

Please check the boxes to indicate that you understand the following about the EXIT Program. *

The EXIT Program is an abstinence based program.(no drugs or alcohol; methadone and suboxone are permitted)
The EXIT Program is NOT a housing first program. First and second phase housing is for participants of the EXIT Program ONLY.
The EXIT Program is NOT a treatment program, it is a life skills recovery program.
The EXIT Program consists of full-time programming. (Monday - Friday, 9:00am-4:00pm)
The EXIT Program is a long-term 12+ month program.

EXIT PROGRAM PARTICIPATION

Please share with us why you think the EXIT Program is suitable for you?

Have you participated in the EXIT Program before?

If you are a past participant, why would you like to return and what will be different this time?

Please check the boxes to indicate that you understand the following RULES for participation in the EXIT Program. *

CURFEW: Participants must be home by 10:00pm (weekdays) and 11:00pm (weekends)
SOBRIETY: Participants must maintain sobriety while participating in the EXIT Program. Random drug/alcohol testing may be required.
DRESS CODE: Participants must follow the dress code. (no crop tops, short clothing or revealing attire)

While on the wait list for the EXIT Program, how concerned are you for your safety? *

Not Concerned
Somewhat Concerned
Very Concerned

LEGAL MATTERS

Do you have any court dates?

If yes, with which court (family, criminal)

If yes, what are your court dates?

Do you have a lawyer?

If yes, please provide your lawyers name

If yes, please provide your lawyers phone and/or email

Are you on probation or parole?

If yes, please provide your Probation/Parole Officer's name

If yes, please provide your Probation/Parole Officer's phone/email

CHILDCARE

The EXIT Program supports women who are pregnant and/or have children. Please provide the following information so we can assess how to best support you.

Are you currently pregnant?

Do you have any children who will be in your care while in the program?

None
Yes, pregnant
1 or more

If you answered 1 or more, please provide the age and gender of your child/children.

SUBSTANCE USE HISTORY

What is your drug(s) of choice?

When was the last time you used drugs or alcohol?

Within 24 hours
In the last week
In the last month
More than a month ago

How often do you typically use

Daily
4 or more times a week
2-3 times a week
weekly
None

Are you currently enrolled in a treatment program or planning to enroll before coming to the EXIT Program?

Do you require a medical detox before coming to the EXIT Program?

MEDICAL HISTORY

Please indicate if you have received any of the following diagnosis.

Mental Health

Bipolar Disorder
Borderline Personality Disorder (BPD)
Depression/Depressive Disorder (MDD)
Generalized/ Social Anxiety Disorder
Panic Disorder
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Complex PTSD
Schizophrenia
Psychosis
Suicidal Ideation
Self-Harm Behaviors
Other (please provide details in the space below)

Other (Mental Health)

Cognitive

ADHD
Learning Disabilities
Fetal Alcohol Spectrum Disorder (FASD)
Autism Spectrum Disorder (ASD)
Other (please provide details in the space below)

a USE #5

Other (Cognitive)

Disordered Eating

Anorexia
Bulimia
Binge Eating
Other (please provide details in the space below)

Other (Disordered Eating)

Do you have any medical conditions you have been diagnosed with that we need to be aware of?

Please note any physical medical conditions that you have received diagnosis for or are currently receiving treatment for so we know what support may be required.

Do you have any allergies?

None
Food
Medication
Environmental

If you have allergies, please provide details on the severity of your allergy below.

Current Medications

Please list all prescribed and over-the-counter medications you are currently taking.

Medication Name and Dosage #1

Medication Name and Dosage #2

Medication Name and Dosage #3

Medication Name and Dosage #4

Medication Name and Dosage #5

Other

Acknowledgement

I, the undersigned, hereby acknowledge that I have provided the above information to the best of my ability.

I understand that this form is confidential and will only be used for my care and safety.

Please type your name below to confirm the above stated acknowledgement. *

Date Signed *