Empowered Network | Survivor Form

Survivor Form

20852

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GET INVOLVED > EHN NOMINATION FORM

EHN NOMINATION FORM

Please fill out the form entirely!

* indicates required fields

EHN supports survivors of human trafficking who are ready to take their next step toward independence.

We currently focus on housing, education, and employment – but are always willing to pursue other gaps that exist in services if we can.

NOMINATIONS CRITERIA

Nominee Information

Country of Origin *

Gender Identification: *

Pick all that apply.

Race and Ethnicity *

Date of Birth *

Immigration Status *

Type of Trafficking *

Financial Wellness

Empower Her Networks works to EMPOWER members to reach fiscal independence over the course of a 12-18 month time period, based on personal goals and aspirations. The following questions/ answers will be used as a baseline to help determine your best Financial Wellness Empowerment Plan moving forward!

Annual Household Income *

Monthly Expenses Estimate *

Monthly Income Current *

Monthly Income Goal *

Nominee Employment & Background Information

Employment Status *

Where Employed *

If not, unable to work reason

Number of Children *

Languages Spoken *

Highest Education Level Completed *

Address 1 (If Shelter List Name). *If at a confidential location, please note confidential *

City *

State *

Zip *

County *

Enter the county that your address is in within your state

EHN believes that survivors are their own solutions. Our support comes in removing barriers and providing advocacy when necessary. With this in mind answer the following:

Areas of support EHN can offer *

Survivor goals *

Survivor strengths and limitations *

Anything important for us to know *

Information about your background and current life situation that is important for us to know

Known triggers *

EHN is a trauma informed service provider that works through the survivor lens. What would you like to share that would be helpful for your advocate to know regarding your experiences, past or present that have the potential to cause emotional or mental distress often referred to as triggers.

Other pertinent details (unsafe locations, addictions, and length of sobriety, etc.) *

Voluntary

You have an option of submitting a statement of interest to submit with this application. Tell us what you hope to accomplish with EHN! Attach Word document here.

Upload Documents

Click or drag a file to this area to upload.

Additional Information

As an anti-trafficking organization EHN is often asked about the overlap in experiences of addiction, incarceration, child welfare and disabilities with experiences of trafficking.

If you feel comfortable, please answer yes or no to the following, so we can include you in relevant opportunities related to policy, advocacy, or eligibility for available financial benefits or changes in state laws that we are made aware of.

These answers have nothing to do with eligibility for our program, nor do they have any effect on your nomination. Any responses will be kept completely confidential.

Were you in the foster care system as a child?

Do you identify with having a disability?

Do you have a history of substance use/addiction?

Do you have a history of incarceration?

If yes, do you have open warrants or vacature/expungment needs? Please list what state(s).

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