Residency Application by Rjow-536 | Oct 15, 2017 Apply Online *Full Legal Name*Date*Do you have a phone? If yes, please give phone number *How did you hear about Poiema Foundation?*Emergency contact / Supportive Friend / Family member:*Relationship to Supportive Contact*Phone of Supportive Contact*Referring OrganizationDate and time of initial contact Referring representative and phone number*Applicant's Form of IdentificationID number and expiration date*Date of Birth*Age*Weight*Height*What are your present living conditions?Current Address:SS Number*Are you an American citizen? If no, what is your country of origin?*Do you have any minor children?*If so, what are their names?Who is responsible for the care of your child(ren)?How often do you interact with your child(ren)?What are the needs of your children at the present time (i e care giving, medical needs)?Are you responsible for monthly child support payments? If yes, what are your current payment amount(s)?*Have you ever been arrested? If yes, please list charge(s) and year(s) of arrest(s) *Have you ever been incarcerated? If yes, please list institution and length of time served *Are you on probation?If yes, who is your Probation Officer? Include name and phone number *Do you have any outstanding warrants?*Do you have any upcoming court dates?If yes, please give details of the situation as well as dates and locations of upcoming court appointments *Are you a registered sex offender? If yes, please give details of the situation Legal counsel (if applicable) Include name and phone number Your answer*Are you pressing charges against your trafficker? If yes, have you connected with law enforcement already?*What is the highest grade you completed?Do you have a GED? Have you been to college? If so, what college and how many credit hours have you completed?*What are your educational goals?*Are you enrolled in Medicaid?*Are you enrolled in the Food Stamp Program?*Are you enrolled in any other Government Assistance Program? If yes, please explain *Have you been involved with any other assistance programs? If yes, please list If yes, why and when did you leave?*Are you currently taking any prescription or over the counter medications on a regular basis?*Have you ever used any of the following substances? Please list and tell us the length of use and date of last use for each Heroin, Cocaine, Crack, Marijuana, LSD, PCP, Methamphetamine, Barbiturates, Alcohol, Synthetic weed, Any other *What is your most recent drug of choice?*Are you currently or have you ever been in a methadone program?*Do you have Hepatitis?*Have you ever been tested for Hepatitis?*Do you have HIV/AIDS?*Have you ever been tested for HIV/AIDS?*Do you have Tuberculosis?*Have you ever been tested for Tuberculosis?*Do you smoke cigarettes? If yes, how many packs a day *Do you wear glasses/contacts?*Do you have any allergies?*Do you have any significant medical conditions?*Are you able to participate in a busy lifestyle that includes: short hikes in the woods, riding horses, and swimming, jogging, aerobic exercise?*Do you have any dental needs?*Are you pregnant? If yes, approximate due date If yes, do you have contact with the biological father?*Do you take psychotropic drugs, anti-depressants, anti-anxiety medications? If yes, list *In the past three years have you survived any of the following? Please list and give a short detailed description for each Death of a parent, close relative, or child Significant or life-threatening illness Financial crisis Homelessness Relocation Threatened with a weapon Assaulted or injured by another person Rape or sexual assault Life-threatening accident Been the victim of a crime Other*Do you have difficultly sleeping? If yes, please describe *Tell us about your moods and how you cope with extreme emotions *Tell us about any social anxiety issues *Are you afraid of dogs?*At what age did you first enter the commercial sex industry?*Have you ever been forced to have sex for money or drugs?*Have you ever had to give your money and/or personal belongings to a pimp/manager?*Have you ever felt threatened by anyone if you were to choose not to have sex for money?*Do you feel threatened at this time?*Do you wish to continue working in the commercial sex industry?*Do you have contact with anyone from your time in the sex industry?*What is the total length of time you were in the sex industry?*Are you hiding from anyone at this time?*Do you feel your trafficker/pimp will attempt to locate you wherever you go?*Are there any security issues you feel we need to know about prior to you entering our care?*What conditions or environments make you feel safe?*Have you ever gotten yourself out of a threatening situation? If yes, how?*Have you ever attacked/assaulted another person? If yes, please describe the circumstance and action taken *What makes you angry and how do you typically react to anger triggers?*In what ways do you feel you are unsuccessful in dealing with your anger?*What are good coping strategies for you?*Have you ever caused yourself bodily harm? If yes, please describe:*Have you ever attempted suicide? If yes, when?*Have you attempted suicide in the past year? If so, how many times?*Do you feel like harming yourself at this time? If yes, what is your plan to harm yourself?*Have you suffered from any eating disorders? If yes, please describe:*Have you ever been in any program or treatment for body image or eating disorders?*Do you have issues with bladder or bowel control?*Are you able to perform basic household chores?*In what areas would you like to learn how to better care for yourself or others?*What do you do for physical fitness?*Please give a brief summary of your time spent in 'the life' How did you come to be involved? How did you exit? Where is your trafficker now?*What are your expectations of Poiema Foundation?*Why do you want to come into our program?*What have you been told about Poiema's house?*What questions do you have for us?*Is there anything else you feel we need to know about your situation? Fields with (*) are compulsory.
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