If you need immediate help or are in danger, call the Human Trafficking Hotline: 888-373-7888

Dorothy’s House Program Application

Dorothy’s House does not provide emergency housing. 

Our intake process takes two weeks on average. The first step is to complete this form. After this form is submitted, the Director of Operations will reach out to the candidate within 48 hours (Monday – Friday between 9am – 5pm CST).

During the intake process, we may require:
– 2 – 3 interviews
– Releases of information with care providers
– Verification of criminal history
– Verification of employment history
– Verification of rental history

Acceptance will be determined within two weeks.
If an applicant is accepted, move-in will be scheduled within 1-3 weeks.

Intake Form
Is it safe to call you?
Are you safe?
Pronouns *
Does the candidate intend to smoke/vape? *
Highest level of education completed

Trauma History

Candidate has experienced (Check all that apply): *
Was the trauma/victimization ongoing? *
Are any of the candidate's perpetrators still a threat? *
Is the candidate still in contact with any perpetrators? *
Is there an open or pending legal case against any of the perpetrators? *
Has the candidate ever been affiliated with a gang? *

Mental Health Information

Please select all mental health diagnoses that apply: *
Has the candidate experienced a crisis and/or hospitalization in the last:
Has the candidate ever had suicidal ideations or attempts? *

Medical Information

How does the candidate attend appointments? *
Does the candidate have any allergies? *
Candidate rates their current physical health as: *
Candidate currently manages their medications: *
Does the candidate have any physical mobility issues? *
Does the candidate have/need any assistive devices?
Does the candidate have a doctor-ordered diet?
Does candidate have any of the following medical conditions? *

Legal History

Does candidate have a criminal history? *
Is the client currently involved in any of the following legal matters? (Check all that apply.) *
Is the candidate involved in any legal proceeding as a victim or witness? *
Has candidate ever harmed others with any type of violence?
Has the candidate ever engaged in destruction of property? *
In communication, is the candidate most often: *

Substance Use History

Does candidate OR has candidate ever used/abused any of the following? (Check all that apply.) *
Does the candidate believe they have an addiction problem? *
Have others told the candidate that they have a problem? *
What is the candidate's using pattern? *
Has the candidate ever received services for substance use? *
Does the candidate want addiction/recovery services? *

Transportation/ Mobility

What transportation does client typically use? *
Is the candidate willing to utilize the DART bus system for transportation if accepted into the program? *
If the candidate is not currently located in Des Moines, do they have access to transportation if accepted into the program? *
Does the candidate own a personal vehicle? *
If the candidate owns a personal vehicle, is it registered and insured?
Is the vehicles title in the candidate's name?

Natural Supports

Children (Skip if candidate has no children)

Is the candidate in contact with any of their children?
Does the candidate have any needs related to their children?
Are any of the candidate's children shared with a perpetrator?


Do you have a monthly income source? Check all that apply.
Do you have insurance? *

Service Needs (Must be completed by candidate)

Other Organizations


Braking Traffik provides comprehensive, trauma-informed services to victims of sex and labor trafficking, including: housing, counseling, medical and court advocacy, and resources and referrals. Their mobile advocates meet survivors where they are. This organization also offers training and public awareness. Located in Davenport.

Service Area: Clinton, Jackson, Louisa, Muscatine, and Scott counties

Crisis line: 1.866.921.3354



Catholic Charities provides legal and medical advocacy, crisis counseling, groups and classes, safety planning, housing, and economic advocacy and shelter. Located in Council Bluffs.

Service Area: Audubon, Cass, Fremont, Harrison, Mills, Montgomery, Page, Pottawattamie, and Shelby counties

Crisis line: 1.888.612.0266



Chains Interrupted provides transitional housing for survivors of sex trafficking. Services for participants in the housing program include sliding-scale rent, assistance with daily living expenses and survivor advocacy like referrals, help obtaining further education and employment, medical care, childcare and legal services. The organization also provides survivor-led support group to survivors of sex or labor trafficking. Located in Cedar Rapids.

Service Area: Benton, Black Hawk, Buchanan, Cedar, Iowa, Johnson, Jones, Linn, and Washington counties

Emergency line: 1.319.536.2027

Non-emergency line: 1.319.369.4415



Friends of the Family provides comprehensive, trauma-informed services to victims of sex and labor trafficking including relocation; safety planning; shelter; counseling; medical, legal and general advocacy; resources and referrals; crisis intervention; and support groups. Their mobile advocates meet survivors where they are. This organization also offers training and public awareness. Located in Waverly.

Service Area: Allamakee, Benton, Black Hawk, Bremer, Buchanan, Chickasaw, Clayton, Delaware, Dubuque, Fayette, Howard, Jones, Linn, and Winneshiek counties

Crisis line: 1.800.410.7233