Resident Application

Today's Date:

Date.

First name:

Please enter your first name.

Last name:

Please enter your last name.

DOB:

DOB.

Address.

Phone:

Please enter your phone number.

Emergency Contact Name:

Emergency Contact Name.

Emergency Contact Phone:

Emergency Contact Phone.

What is your ethnicity?

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Non-Latino or White Native Hawaiian or Other Pacific Islande

Do you have any children?

Do you have a custody arrangement in place?

Who are you referred by?

Who is completing this application?

What is your first drug of choice?

What is your second drug of choice?

List other drugs you have used.

How many years have you been using?

How long have you been sober?

Please describe any inpatient alcohol and drug treatment programs, intensive outpatient programs, and/or other recovery programs you have been in:

Do you have a history of prostitution?

Have you experienced trafficking?

Do you have a history of sexual abuse/assault?

Do you have any physical disabilities, chronic, or ongoing conditions?

High Blood Pressure Heart Disease Asthma Respiratory Difficulty Chronic Gum and/or Dental Pain

Other:

Other

Have you ever received a Mental Health Diagnosis?

If so, please descirbe:

Have you ever been hospitalized for any medical/ psychiatric reasons?

If so, please descirbe:

Have you ever attempted suicide?

Do you receive Social Security Income or Social Security Disability?

Do you have any arrest records?

Have you ever been charged as a sexual offender?

Do you have any warrants/pending charges in any state and/or county?

If so, please descirbe:

Are you currently on probation?

Have you been court ordered to go to inpatient treatment or are you applying voluntarily?

What is your highest level of education?

What types of jobs have you had in the past?

Is it safe for a Jasmine Road staff member to follow up with you regarding your application with the phone number you listed?

If there are any concerns regarding your safety, please describe the best way a Jasmine Road staff member can contact you:

Is there anything else you would like to share about yourself with the Jasmine Road staff?

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