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Need Help? Contact Us.
Name:*
Last Name:*
Birthday: 00/00/00*
Number You Can Be Reached At*
Email Address:*
Are you still involved in prostitution?*
Yes
No
What age did you become involved in prostitution?*
How long have you been involved in prostitution?*
What is your current living situation?*
Do you currently have a pimp?*
Yes
No
Do you currently have children living with you?*
Yes
No
If yes, how many and what are their ages?
Are you currently addicted to drugs or alcohol?*
Drugs
Alcohol
Both drugs and alcohol
None of the above.
.Have you been through a drug or alcohol program?*
Yes
No
Are you willing to commit to a program to get help?*
Yes
No
How did you hear about us?*
TV Show
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Hookers for Jesus
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Anything else you would like us to know?