Jasmine Road

Maiden name (if applicable):

Please enter your maiden name.

Alias or other names used (if applicable):

Please enter your alias.

What is your ethnicity?

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

If we do not have an opening in our program, would you be open to applying to one of our Sister Organizations?

Do you have any geographical limitations or state preferences?

Do you have any geographical limitations or state preferences

Please select the option that best describes your current living situation.

Please summarize your housing history over the last 6 months:

Describe your relationship with your family:

Describe your relationship with your family

Please provide their names and ages:

Please provide their names and ages

List other drugs you have used.

How old were you when you started using drugs/alcohol?

How many years have you been using?

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

How old were you when you entered trafficking or prostitution?

How many years have you been in the game of trafficking or prostitution?

Please briefly describe your trafficking / prostitution history (i.e. escort services, pimp, online advertising, streets, etc.)

Please briefly describe your trafficking / prostitution history

If yes, is this relationship something that you are hoping to continue while you are enrolled in the Jasmine Road program? Please explain.

If yes, is this relationship something that you are hoping to continue while you are enrolled in the Jasmine Road program

If yes, please list all medications you are currently taking:

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 been hospitalized for any medical/ psychiatric reasons?

Do you receive Social Security Income or Social Security Disability?

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

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

Please also list any specialized classes, program, licenses or anything else you would like us to know about:

specialized classes, program, licenses

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?

Confidentiality: Identity-related information is protected by our confidentiality policy, and any data collected on applicants will be used to further the mission of Jasmine Road and for continuous improvement of the quality of the program and its services for program participants. Demographic data collected may be shared with researchers, community stakeholders, funding sources, or other qualified entities to accurately describe the backgrounds and demographics of populations served and the services rendered by Jasmine Road and its partners. Data will also be used to track and quantify community impact, effectiveness of service, and to identify areas where improvement is needed. Whenever data is shared outside the Jasmine Road organization, resident identities remain confidential. Confidentiality is Jasmine Road’s number one priority, to ensure the safety and security of the women in its program. Personal identifying information such as full names, agges, birthdays, children or family names/information, contact information, and social security numbers belonging to residents are never shared outside the Jasmine Road organization.

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Resident Application