Online Resident Application

Oasis House Resident Application

Office: 1133 S Edwin C Moses Blvd, Suite 384, Dayton, Ohio 45404 Phone: 937-898-7811
The Oasis House Residential Program aims to provide female survivors of human trafficking with safe, transitional housing opportunities in order to provide a stable home environment, accompanied by services focused on developing life and occupational skills to allow survivors to overcome their individual traumas. The Program is designed to encourage and support additional mental health, substance abuse, and physical health treatment to allow survivors to realize their full potential.

The Residential Program is designed to be longer in term, if necessary, based on the individual's needs. Please provide a 2-page letter stating why you want to be a part of Oasis House's housing program. During the Residential Program, residents will receive individual counseling, referral services for medical treatment, regular group meetings with other survivors, and spiritual counseling.

The resident may be terminated from the program at any time if the resident is not participating in required activities, is not making sufficient progress towards successful completion of the program, or fails to comply with the Housing Rules and Regulations.

The following are the minimum eligibility requirements for a resident to be considered for the Oasis House Residential Program:
- Female
- Over the age of 18
- Not the current custodial parent or guardian for any children
- Able to provide self-care and self-administer medication; No needs for handicapped-accessible housing; No medial conditions which warrant significant treatment and/or intervention
- Able to climb stairs
- Mentally capable of processing new information; capable of verbal and written communication
- Mentally and emotionally stable; no reported suicide attempts in three (3) months; No antipsychotic medications
- Sober for at least thirty (30) days
- Not a registered sex offender
- Oasis House is not a sober living facility

Please read and understand this page. Signatures will be obtained during final approval.
A staff member of Oasis House has read through and discussed with me the Residential Program requirements. I understand that if I agree to participate in the program, Oasis House staff will work with me to put together an individualized recovery program that identifies and obtains the services that meet my needs, whether those services be provided by Oasis House or a third party. I also understand that no specific outcome can be guaranteed.

I understand that nay services extended to me by Oasis House or a third-party provider requires my cooperation. By signing this application, I agree that I will comply with directives of the individualized recovery program, and will attend and participate in evaluations and assessments for purposes of treatment, individualized therapy, and growth.

I have been provided a copy for the Residential Program No-Tolerance Policy and Code of Conduct. By signing below, I have reviewed the Oasis House No-Tolerance Policy and Code of Conduct and agree that if I am accepted into the Program I will agree and sign.

______________
Date

____________________________
Applicant Signature

____________________________
Applicant Printed Name

____________________________
Witness Signature

I understand that Oasis House regularly evaluates the effectiveness of their programs and services. I am GRANTING / NOT GRANTING (circle one) Oasis House permission to use my Residential Application, Intake Form(s), and Follow-Up interviews to use in evaluation and development of Oasis House's current programs.

I recognize that my information will remain confidential at all times, and if I decide to NOT GRANT or later REVOKE permission to use my information, it will in no way affect my application, admission to, or participation in the Residential Program.

_____________________________
Signature

______________
Date

Please note: it will take 30 to 60 minutes to complete this application.
Date of Application

Month Day Year
Name of person assisting with application
Release date from current program:
I. Personal Information
Full Name *
Date of Birth
MM/DD/YYYY
Age
Maiden Name
Current Address

Street Address

County of Residence

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Email
example@example.com
Race:

Caucasian African American Asian American Hispanic Other
Do you have a copy of your birth certificate?

Yes No
Do you have a driver's license or state ID?

Yes No
In case of an emergency, whom should we contact?
Name
Your relationship to the emergency contact?
Relationship
Phone number of your emergency contact?
Contact Phone Number
Emergency contact address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

VIII. Criminal Justice/Incarceration Information
If you are currently incarcerated, please answer the following:
Where are you incarcerated?
What is your sentence?
When will you be eligible for probation/parole?
If you are not currently incarcerated, please answer the following:
On Probation?

Yes No
On Parole?

Yes No
Diversion program?

Yes No
If YES to any of these, please provide the following:
Approximate number of arrests:
Approximate number of incarcerations:

List of most recent charges and sentences

	Charge Description	Sentence Description
Charge 1
Charge 2
Charge 3
Charge 4

Do you have any active warrants?

Yes No

If YES, please provide:

	Charge Description	Court
Charge 1
Charge 2
Charge 3
Charge 4

You MUST click the Submit to record your application. A staff member from Oasis House will be in contact with you soon.
Should be Empty:

	Still Using	Not Using	Sober since	Age when Started
Cigarettes
Alcohol
Prescription Meds
Illegal Drugs

	Yes	No	Age
Neglect
Separation from primary caregiver
Family secrets
Emotional abuse
Physical abuse
Sexual abuse
Witness abuse of others
Alcohol/drug abuse by caregivers

	Yes	No
Memory lapses
Spacing out
Losing track of time
Headaches / Migraines
Auditory Hallucinations
Habitual lying
Flashbacks
Nightmares
Suicidal ideation
Homicidal ideation

Oasis House Resident Application