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Residency Application

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How did you hear about Poiema Foundation?*

Referring Organization

Did an organization refer you to Poiema Foundation?*

Yes

No

Referring Organization*

Referring Representative*

First Last

Representative Phone Number*

Date and time of initial contact

Date of Initial Contact*

MM slash DD slash YYYY

Time of Initial Contact

Hours

:

Minutes

AM/PM

Applicant Information

Full Legal Name*

First Middle Last

Would you prefer to be contacted by phone or email?*

Phone

Email

Other

Please provide your email address.*

Please provide your phone number.*

How would you like to be contacted?*

Emergency Contact / Supportive Friend / Family Member*

Name

Relationship

Phone

Click the + next to the above row to add multiple contacts.

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What is your form of Identification?*

Hidden

Id Number

Hidden

Expiration date

MM slash DD slash YYYY

Date of Birth*

MM slash DD slash YYYY

Age*

Hidden

Weight*

Hidden

Height*

What are your present living conditions?*

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you an American citizen?*

Yes

No

Country of Origin*

Children

Do you have any minor child(ren)?*

Yes

No

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Who is responsible for care of your child(ren)?*

First Last

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What are the needs of your children at the present time (i.e. care giving, medical needs)?

How often do you interact with your child(ren)?*

Are you responsible for monthly child support payments?*

Yes

No

What are our current payment amount(s)?

Legal History

Have you ever been arrested?*

Yes

No

List charge(s) and year(s) of arrest(s).*

Charge

Year of arrest

Click the + next to the above row to add multiple arrests.

Have you ever been incarcerated?*

Yes

No

List institution(s) and length of time served.*

Institution

Length of time served

Click the + next to the above row to add multiple institutions.

Are you on probation?*

Yes

No

Probation Officer Name*

First Last

Probation Officer Phone

Do you have any outstanding warrants?*

Yes

No

Are you a registered sex offender?*

Yes

No

Please give details of the situation.

Are you pressing charges against anyone who has exploited you?*

Yes

No

Have you connected with law enforcement already?*

Yes

No

Do you have legal counsel?

Yes

No

Do you need help obtaining legal counsel?

Yes

No

Legal counsel name

First Last

Legal counsel phone number

Do you have any upcoming court dates?*

Yes

No

Please give details of the situation as well as dates and locations of upcoming court date(s).*

Education

What is the highest level of schooling you have completed?*

Do you have a GED?*

Yes

No

Have you been to college?

Yes

No

List

College

Credit hours completed

Do you want to continue your education?*

Yes

No

What are your educational goals?*

Assistance Programs

Select all benefits you are currently receiving.

Medicaid

Food Stamp

Other Government Assistance

Other Nongovernment Assistance

Please explain the other Government Assistance your currently receiving.*

Please list the Nongovernment Assistance you are currently receiving.*

Did you leave any of the assistance programs?*

Yes

No

Please explain why and when you left the assistance program(s).

Substance Use

Are you currently taking any prescription on a regular basis?*

Yes

No

Do you take psychotropic drugs, anti-depressants, anti-anxiety medications?*

Yes

No

Please list the psychotropic drugs: anti-depressants, anti-anxiety medications you are currently taking*

Have you ever used any of the following substances?*

Heroin

Cocaine

Crack

Marijuana

LSD

PCP

Methamphetamine

Barbiturates

Alcohol

Synthetic weed

Any other

None

Heron Length of Use*

Heroin Date Last Used

MM slash DD slash YYYY

Cocaine Length of Use*

Cocaine Date Last Used

MM slash DD slash YYYY

Crack Length of Use*

Crack Date Last Used

MM slash DD slash YYYY

Marijuana Length of Use*

Marijuana Date Last Used

MM slash DD slash YYYY

LSD Length of Use*

LSD Date Last Used

MM slash DD slash YYYY

PCP Length of Use*

PCP Date Last Used

MM slash DD slash YYYY

Methamphetamine Length of Use*

Methamphetamine Date Last Used

MM slash DD slash YYYY

Barbiturates Length of Use*

Barbiturates Date Last Used

MM slash DD slash YYYY

Alcohol Length of Use*

Alcohol Date Last Used

MM slash DD slash YYYY

Synthetic Weed Length of Use*

Synthetic Weed Date Last Used

MM slash DD slash YYYY

Other Substances*

Other Length of Use*

Other Date Last Used

MM slash DD slash YYYY

What is your most recent drug of choice?*

Are you currently or have you ever been in a drug or alcohol rehab program?*

Yes

No

Medical History

Have you ever been tested for Hepatitis?*

Yes

No

Do you have Hepatitis?*

Yes

No

Have you ever been tested for HIV/AIDS?*

Yes

No

Do you have HIV/AIDS?*

Yes

No

Have you ever been tested for Tuberculosis?*

Yes

No

Do you have Tuberculosis?*

Yes

No

Do you smoke cigarettes?*

Yes

No

How many packs a day?

Do you wear glasses/contacts?*

Yes

No

Do you have any allergies?*

Yes

No

What are you allergic to?*

Do you have any significant medical conditions?*

Yes

No

What is the significant medical condition?

Are you able to participate in a busy lifestyle that includes: short hikes in the woods, riding horses, and swimming, jogging, aerobic exercise?*

Yes

No

Please explain what keeps you from participating in a busy lifestyle.

Are you pregnant?*

Yes

No

Approximate due date

MM slash DD slash YYYY

Do you have contact with the biological father?*

Background in the Commercial Sex Industry

Have you ever been forced or felt threatened to have sex for money, drugs or basic necessities?*

Yes

No

Have you ever had to give your money and/or personal belongings to a pimp/ex?*

Yes

No

Do you wish to continue working in the commercial sex industry?*

Yes

No

Where is your perpetrator/pimp/ex now?

Do you have contact with anyone from your time in the commercial sex industry?*

Yes

No

Do you feel your perpetrator/pimp/ex will attempt to locate you wherever you go?*

Yes

No

At what age were you first exploited?*

What is the total length of time you were in the commercial sex industry?

Please give a brief summary of your time spent in commercial sex industry.*

How did you exit commercial sex industry?*

Physical/Emotional Health

Select all of the following that you have experienced.

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

Hidden

Please provide a short description of the death of a parent, close relative or child.

Hidden

Please provide a short description of the significant or life-threatening illness.

Hidden

Please provide a short description of the financial crisis.

Hidden

Please provide a short description of experiencing homelessness.

Hidden

Please provide a short description of the relocation.

Hidden

Please provide a short description of being threatened with a weapon.

Hidden

Please provide a short description of the assault or injury by another person.

Hidden

Please provide a short description of the rape or sexual assault.

Hidden

Please provide a short description of the life-threatening accident.

Hidden

Please provide a short description of being a victim of a crime.

Hidden

Please provide a short description of the other incident.

Do you have difficulty sleeping?*

Yes

No

Describe your difficulty sleeping.*

Tell us about your moods and how you cope with extreme emotions.*

Do you have social anxieties?*

Yes

No

Tell us about your social anxieties.*

Are you afraid of dogs?*

Yes

No

Do you feel threatened at this time?*

Yes

No

What makes you feel threatened at this time?

Are you hiding from anyone at this time?*

Yes

No

Who are you hiding from?

Are there any security issues you feel we need to know about prior to you entering our care?*

Yes

No

Describe the security issues.*

What conditions or environments make you feel safe?*

Have you ever gotten yourself out of a threatening situation?*

Yes

No

How did you get yourself out of a threatening situation?*

Have you ever attacked/assaulted another person?*

Yes

No

Please describe the circumstance and action taken when you attacked/assaulted another person.*

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?*

Yes

No

Describe how you caused yourself bodily harm?*

Have you ever attempted suicide?*

Yes

No

Please explain when and how you attempted suicide.*

How many times have you attempted suicide in the past year?*

Do you feel like harming yourself at this time?*

Yes

No

What is your plan to harm yourself?*

Have you suffered from any eating disorders?*

Yes

No

Describe the eating disorders.*

Have you ever been in any program or treatment center?*

Yes

No

Please provide any program or treatment center you have participated in.

Click the + next to the above row to add multiple programs.

Do you have issues with bladder or bowel control?*

Yes

No

Are you able to perform basic household chores?*

Yes

No

Please explain what keeps you from performing basic household chores?

Would you like to learn how to better care for yourself or others?*

Yes

No

In what areas would you like to learn how to better care for yourself or others?

What do you do for physical fitness?

Is there anything else you feel we need to know about your situation?*

Yes

No

Please describe anything else you feel we need to know about your situation.*

Your Expectations of Our Program

Please describe why you want to come into our program and what you hope to accomplish.*

What have you been told about Poiema's Safe House?

Do you have any questions for us?*

Yes

No

Let us know any questions you have about Poiema.*

Δ

Our Hope Is...

A world where sexual abuse and exploitation is not tolerated; and the victims are fully restored.

Fight Human Trafficking

To donate by check, mail your donation to:

Poiema Foundation
P.O. Box 757
Rockwall, Texas 75087

Poiema Foundation

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