Resident Application

 

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.
Please enter your first name.
Please enter your last name.
DOB.

* Ethnicity?

 
Please enter your email.
Please enter your phone number.
Address.
City, State, Zip.
 

Additional Contact Person:

First name.
Last name.
Relation to applicant.
Phone.
 

 
 
Other
 

 
Other.
 

ADDICTION HISTORY

 
 
 

EXPLOITATION HISTORY

 

RELATIONSHIP HISTORY

 
 

MEDICAL HISTORY

 
List physical health conditions and/or concerns.
 
 
If so, please describe:
 
 
If so, please describe:
 
 
 
 
If so, please describe:
 
 

GOVERNMENT BENEFITS HISTORY

 

CRIMINAL JUSTICE HISTORY

 
 
 
 

WORK READINESS

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

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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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