Resident Application Form - Bloom For Women

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Please read the Application Requirements document also found on the webpage with this application link before completing this form. This application takes 20-40 minutes to complete. As part of the application process, we will be asking personal questions that may include details about your experience with trafficking, your personal history, and medical and legal matters. Your responses are important in helping us understand your situation and provide the best possible support and resources. Please be assured that all information you share will be kept confidential and used solely to assist your care and recovery. Please ensure you have the following information before you begin, as progress cannot be saved: Commercial Sexual Exploitation & Trafficking History; Family Summary; Addiction History; Abuse History; Health History; Arrest History; Education and Work History

**This application will be forwarded to our Intensive Outpatient team.

Applicant's Name *

First

Last

Alias Name (If Applicable)

First

Last

Race *

Primary Language *

Secondary Language

Date of Birth (MM/DD/YY) *

Email (We will use this to contact you) *

Confirm Email

example@example.com

Phone Number *

Area Code

Phone Number

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact *

First

Last

Relationship to Applicant *

Phone Number *

Area Code

Phone Number

Referred By *

Case Manager *

First

Last

Phone Number

Area Code

Phone Number

Email *

Person Completing Form *

First

Last

Relation to Applicant *

Please describe any updates you have to your application. *

If we do not have an opening in our program, would you be open to one of our sister organizations? *

Do you have any geographic limitations or state preferences (if they can be accommodated)? *

COMMERCIAL SEXUAL EXPLOITATION & TRAFFICKING (CSET)

What is CSET? Commercial Sexual Exploitation: Any sexual activity that is traded or exchanged for something of value (or the promise of something of value), often for the purpose of survival. Sexual activity also includes pornography, stripping, exotic dancing, escorting, erotic massage, and street exploitation. Something of value includes but is not limited to, money, a place to stay, food, clothes, rent, transportation, drugs, medication, or survival. Trafficking: any commercial sexual activity where there is a third-party exploiter ("Daddy", partner, boyfriend, trafficker, manager, facilitator, family member) that aids in the commercial sexual exploitation of an individual.

Do you have a history with Commercial Sexual Exploitation & Trafficking (CSET)? *

SATANIC RITUAL ABUSE (SRA)

SRA refers to allegations of systematic and ritualistic abuse that purportedly involves the worship of Satan or other dark forces. Survivors may describe a range of experiences, including physical, sexual, and psychological abuse, as well as participation in rituals with occult themes.

Do you identify as being a survivor of SRA? *

Who do you live with now? *

Who did you live with in the past? *

Can you describe your current and past living conditions? *

Have you ever been forced to do things you didn't agree to? *

Have you ever felt coerced or pressured into exchanging sexual acts in order to obtain money, housing, drugs, or safety? *

Has anyone ever threatened you or your family to make you do something you didn't want to do? *

Has anyone ever taken your documents away or kept them from you? *

Has anyone threatened to report you to immigration or law enforcement if you don't do what they say? *

Have you ever been afraid of being arrested or deported because of your situation? *

FAMILY SUMMARY

Describe your relationship with your family. *

Do you have children? *

Are you currently pregnant or caring for a child? *

ADDICTION HISTORY

Do you have a history with addiction? *

ABUSE HISTORY & RELATIONSHIP STATUS

Do you have a history of sexual abuse? *

Have you experienced domestic violence? *

Are you currently in a romantic relationship? *

HEALTH HISTORY

Do you have medical insurance? *

Do you receive SSI or SSDI? *

Do you have a payee or a conservator? *

List any inpatient, drug and alcohol treatment, intensive outpatient programs (mental health, substance use, etc.) and/or recovery programs you have attend. Please include the name of the program, the date of service, how long you attended, and what happened). *

Have you ever received a mental health diagnosis? *

Do you have any physical disabilities or conditions? *

Please explain in detail any physical limitations, chronic, or ongoing conditions you may have.

Are you currently taking any medications? *

Have you been hospitalized for psychiatric reasons? *

Have you ever attempted suicide? *

LEGAL HISTORY

Do you have pending charges or warrants? *

Please list pending court dates: *

Number of arrests: *

Number of incarcerations: *

Please list all charges and dates: *

Are you on probation? *

list birth? use,

Are you currently incarcerated? *

MOBILITY

Can you walk for extended periods (ex. 20 minutes at a time)? *

Are you able to go up and down stairs? *

Do you have reliable transportation? *

Do you have access to a car? *

Do you have any specific transportation or mobility needs? *

EDUCATION & WORK HISTORY

What is your highest level of education? *

Describe your work history. *

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