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Pathfinder Center

We serve victims of sex trafficking.

A Program of Wiconi Wawokiya, Inc.

ESCAPE

Protecting and Finding Purpose for Victims of Sex Trafficking

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DOWNLOAD INTAKE FORM

Client #_______________

For Office Use Only

PATHFINDER CENTER Intake/Contact Form

Please fill out the following to apply for our service.

Date of Intake

Date of Birth

Sex

Female

Male

Non-binary

First name

Last name

Email

Phone

Address

City

State

Postal / Zip code

Primary Emergency Contact

Relationship to Emergency Contact?

Emergency Contact Phone

Address for Emergency Contact

Secondary Emergency Contact

Relationship to Contact?

Secondary Emergency Contact Phone

Address for Emergency Contact

Are you a U.S. Citizen?

Yes

No

Do you have a state I.D.?

Yes

No

Are you a Veteran?

Yes

No

I declare that the info I’ve provided is accurate & complete. I understand that this is an initial Intake and Pathfinder Center reserves the right to ask me more in-depth questions to complete our Intake.

Thank You for connecting with us here at Pathfinder Center. We will be contacting you shortly.

To review the entire Intake Form click here.

We are a 501c3 non-profit organization. Donations are deductible as allowed by IRS law.

We serve victims of sex trafficking.
Need Help Now?
Call the National Help Number: 1-888-373-7888

DOWNLOAD INTAKE FORM

Pathfinder Center is proud to partner with:

TV Interview With Executive Director, Lisa Heth

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