Jasmine Road

Jasmine Road serves adult women who are survivors of both commercial sexual exploitation and addiction.

Commercial sexual exploitation includes any sexual activity that is exchanged for something of value or the promise of something of value, often for the purpose of survival. Sexual activity includes pornography, exotic dancing, escorting, erotic massage, or street exploitation. Something of value includes but is not limited to money, a place to stay, food, clothes, rent, transportation, drugs, or survival. Commercial sexual exploitation also includes trafficking, when a third-party exploiter (such as a “boyfriend,” pimp, manager, family member, etc.) aids in someone being sexually exploited.

What to expect after you submit an application:

1. A staff member will call the phone number you provided within 3 business days. PLEASE PROVIDE A RELIABLE NUMBER because after 2 attempts, your application is removed from the waitlist.
2. The staff member will let you know if you are eligible for Jasmine Road
3. If you are not eligible for or accepted into the program, we will refer you to other resources
4. If you are eligible, the staff person will answer your questions about the JR program and schedule a video or in-person interview with you
5. Within 24 hours of your video/in-person, we will let you know if you are not accepted. If you are accepted, we will refer you to other resources.

Date:

Date.

* Applicant first name:

Please enter your first name.

* Applicant last name:

Please enter your last name.

* Date of Birth (MM/DD/YYYY):

DOB.

* Gender Identity:

* 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

Please enter your email.

Phone:

Please enter your phone number.

Address:

Address.

City, State, * Zip:

City, State, Zip.

Additional Contact Person:

First name:

First name.

Last name:

Last name.

Relation to applicant:

Relation to applicant.

Phone:

Phone.

Person completing this application?

Referred by:

Other or Thistle Farms sister organization name:

Other

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

Other:

Other.

ADDICTION HISTORY

* Do you have a history with drug or alcohol addiction?

* Are you currently using drugs and/or alcohol?

* Have you ever been in substance use treatment or rehab before?

EXPLOITATION HISTORY

* Do you have a history of commercial sexual exploitation? (see definition at top of page)

RELATIONSHIP HISTORY

Are you currently married or in a romantic relationship?

Do you have any children?

MEDICAL HISTORY

* Do you have any physical disabilities or chronic (ongoing) conditions?

List physical health conditions and/or concerns.:

List physical health conditions and/or concerns.

* Have you ever received a Mental Health Diagnosis?

If yes, please describe mental health diagnosis.

If so, please describe:

* Have you ever been hospitalized for any psychiatric reasons?

If yes, please describe.

If so, please describe:

* Have you had any suicidal thoughts recently?

* Have you had any suicidal thoughts in the past?

* Are you currently taking any medication?

If so, please list medications including any over the counter medications and reasons for their use.

If so, please describe:

Do you have medical insurance?

GOVERNMENT BENEFITS HISTORY

* Do you receive Social Security Income (SSI) or Social Security Disability Income (SSDI)?

CRIMINAL JUSTICE HISTORY

Do you have ANY arrest records?

* Have you ever been charged as a sexual offender?

Are you currently on probation?

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

WORK READINESS

* Are you legally able to work in the US?

* Are you physically able to work?

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

CAPTCHA

Please enter your response.

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, ages, 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