Client Intake Form

The Mission of the New Light New Life organization is to empower survivors lives of Human Trafficking, and any other form of domestic abuse; by providing new looks and other services that inspire change, create self – worth and promote a new sense of self confidence.

Instructions

Please type, print or complete the online or physical copy of this application.
In order to be accepted, complete your application in its entirety and sign in the designatedsections.
Please complete the application in detail and as honestly as possible
If you need assistance completing the application please reach out to our organization(702)-NEW-LIFE (702)-639-5433
You must currently be with an organization and/or be referred from an organization
All applications must be signed to be accepted. (Photocopies are acceptable)
If you require accommodation related to a disability, notify the Program Manager.
Applications with New Light New Life will take a period of 7 days before being accepted.
After 7 days a member from our team will reach out to you and start your journey of transformation with the New Light New Life organization.
After every 30 days you will be required to submit a new application to keep up with your journey of growth and help our instructors to best fit your needs.

Note**Only authorized personnel will review this form*

Contact Information

Full Legal Name:

Preferred Private Name:

Date of Birth:

Last 4 digits SSN:

Gender

Address

Apt #

City

State

Zip

Contact

General Information

Do you have any relatives enrolled with New Light New Life ?

Ans

If Yes Who?

How did you hear about us?

Outreach flier

Organization

Referral by whom?

Other

Person, Advocate, Attorney helping you complete this application. Tell us about them.

First Name:

Telephone:

Last Name:

Email:

Personal Information

Race:

Maritial Status:

American Indian/ Alaska Native

Marrige

Primary Language:

English

Other:

Highest level of education?

High School Grade Completed Up Until

High School Diploma

GED

College Degree

Are you interested in continued education/ trade?

Yes

If yes please describe what type of education/ trade you'd be interested in learning more about.

Please describe your criminal history.

(if not available please put none)

Type of crime:

Type of Crime

Offender’s Name and Address

(if known for protection purposes)

Please describe how the crime occurred:

Were alcohol or drugs a factor in this crime, in any way?

yes

Please describe how this crime has affected you.

Do you have any triggers?

Yes

please provide detail as to what they may be for you.

Do you struggle with addiction?

yes

If yes please describe.

How long have you been clean/ sober?

Have you ever been employed?

yes

If yes please describe what you did at your last 3 jobs

Are you currently looking for a job?

yes

If yes please describe what field you are looking to work in.

Emergency Contact

Name

Relationship

Phone

Medical History

Do you have any allergies we should be aware of?

yes

If yes please explain

Do you have a disability?

yes

If yes please explain

Do you require specific accommodations?

yes

If yes please explain

Program Connection

Our organization has the following programs available. Please select below what you are interested in being apart of

Values text

Please tell us what you are looking to get from this program at the end of your journey.

By the end of your journey would you be interested in becoming a volunteer mentor for newcomers? “Teaching survivors to survive”

yes

By Signing below I agree to the following - staying clean/ sober

Client Intake Form

Instructions

Contact Information

General Information

Personal Information

Medical History

Program Connection

Useful Links

Locations

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