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

Name *

Phone

Is it safe to call you?

Yes

Are you safe?

Yes

Where are you currently living?

Pronouns *

She/Her/Hers

He/His

They/Them/Theirs

Gender identity

Date of birth *

MM/DD/YYYY

Does the candidate intend to smoke/vape? *

Yes

Current city/state *

Highest level of education completed

I am filling out this form: *

If candidate marked "with help", who is assisting and what is their relationship with the candidate?

Trauma History

How recently did the candidate experience violence? *

Was the trauma/victimization ongoing? *

Yes

If yes, how long did it occur?

Are any of the candidate's perpetrators still a threat? *

Yes

Unknown

Is the candidate still in contact with any perpetrators? *

Yes

Is there an open or pending legal case against any of the perpetrators? *

Yes

Where (cities/states) did the perpetration occur?

Has the candidate ever been affiliated with a gang? *

Yes

If yes, please explain.

Please summarize the trauma history for which the candidate is seeking services:

Mental Health Information

What mental health symptoms does the candidate experience related to each diagnosis? How often? *

What triggers is the candidate aware of? How do they affect the candidate? *

What skills does the candidate utilize to manage mental health symptoms? How effective are the skills? *

Has the candidate OR does the candidate intend to seek Social Security Disability Income for a mental health condition? If yes, please explain. *

How does the candidate manage a mental health crisis? What helps them recover? *

Has the candidate ever received impatient psychiatric treatment? If so, describe the circumstances. *

Has the candidate experienced a crisis and/or hospitalization in the last:

30 days

3 months

6 months

N/A

Has the candidate ever had suicidal ideations or attempts? *

Yes

If yes, when was the most recent episode?

Please list the candidate's current mental health medications. *

Please describe the candidate's last appointment with a psychiatrist or other mental health provider. *

Medical Information

Describe any immediate medical needs. *

List any upcoming appointments.

How does the candidate attend appointments? *

Independently

With assistance

Does the candidate have any allergies? *

Yes

If yes, please list them.

Candidate rates their current physical health as: *

Excellent

Fair

Poor

Candidate currently manages their medications: *

Independently

With assistance

Dependent

Does the candidate have any physical mobility issues? *

Yes

If yes, please explain.

Does the candidate have/need any assistive devices?

Yes

If yes, please explain.

Does the candidate have a doctor-ordered diet?

Yes

If yes, please explain.

List any medications the candidate is taking for medical conditions.

Legal History

Does candidate have a criminal history? *

Yes

Is the candidate involved in any legal proceeding as a victim or witness? *

Yes

If yes, please explain.

Provide an explanation for anything checked above (Name of Probation/ Parole officer and contact information, all requirements, length of time of any orders, etc.).

Has candidate ever harmed others with any type of violence?

Yes

If yes, explain.

Has the candidate ever engaged in destruction of property? *

Yes

If yes, explain.

How does the candidate handle conflict/frustration with others? *

Are there certain traits/behaviors that trigger the candidate? *

Does the candidate have any concerns working with different types of staff or volunteers (male/female/young/etc.)? *

Does the candidate have concerns about living with different types of individuals (race/age/sexual orientation/etc.)? *

In communication, is the candidate most often: *

Passive

Aggressive

Passive/ Aggressive

Assertive

Substance Use History

Does the candidate believe they have an addiction problem? *

Yes

Have others told the candidate that they have a problem? *

Yes

What was the last date candidate used any of the above? *

MM/DD/YYYY

What was the candidate's longest period of sobriety in the last year? *

What is the longest period of sobriety in the candidate's lifetime? *

How long have any of the above been an issue for the candidate?

How does the candidate usually access any of the substances above?

Who does the candidate usually use/drink with?

How many times has the candidate seriously attempted abstinence?

Has the candidate ever received services for substance use? *

Yes

If yes, where and when?

What has worked in the candidate's recovery?

What has not worked in the candidate's recovery?

Does the candidate want addiction/recovery services? *

Yes

If yes, explain.

Transportation/ Mobility

Is the candidate willing to utilize the DART bus system for transportation if accepted into the program? *

Yes

If the candidate is not currently located in Des Moines, do they have access to transportation if accepted into the program? *

Yes

N/A

Does the candidate own a personal vehicle? *

Yes

If the candidate owns a personal vehicle, is it registered and insured?

Yes

Is the vehicles title in the candidate's name?

Yes

If no to either of the previous questions, please explain.

Natural Supports

Who in the candidate's life provides them with support? *

Describe candidate's family of origin (e.g. middle of 4 children, raised by grandparent, raised by single parent.) *

Describe candidate's current relationship with family, including whether family is healthy or unhealthy. *

Children (Skip if candidate has no children)

Is the candidate in contact with any of their children?

Yes

What are the names and ages of their children?

Who is/are the primary caretaker(s) of their children?

Does the candidate have any needs related to their children?

Yes

If yes, explain.

Are any of the candidate's children shared with a perpetrator?

Yes

Please share any other relevant information.

Financial/Insurance

Service Needs (Must be completed by candidate)

How long do you see yourself needing services? *

What do you need and/or expect from Dorothy's House? *

What would successful completion of a program look like for you? *

What would you like to be able to do one year from now that you are unable to do today? *

Have you used services from another program? If yes, describe what worked and didn't work for you and why. *

Have you ever been evicted, denied, and/or removed from services? If yes, explain. *

What are some of your hobbies or interests? *

What are some of your strengths? *

Describe any special needs that Dorothy's House should be aware of. *

reCAPTCHA

If you are human, leave this field blank.

Other Organizations

BRAKING TRAFFIK (FAMILY RESOURCES)

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

http://famres.org

CATHOLIC CHARITIES

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

http://www.catholiccharitiesdm.org/our-services/domestic-violence-shelter/

CHAINS INTERRUPTED

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

http://www.chainsinterrupted.com

FRIENDS OF THE FAMILY

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

http://fofia.org