• Oasis House Resident Application

    Office: 1133 S Edwin C Moses Blvd, Suite 384, Dayton, Ohio 45417 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 twelve (12) 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.

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  • I. Personal Information

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  • Race:
  • Do you have a copy of your birth certificate?
  • Do you have a driver's license or state ID?

  • II. Family History

  • Marital Status
  • Are you
  • Is your significant other
  • Do you have any children?
  • Do you currently have visitation rights with any of your children?

  • III. Education History

  • Which is the highest grade you have completed?
  • Have you received vocational training?
  • Are you currently taking any educational classes?

  • IV. Substance Abuse History

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  • Are you receiving Medication Assisted Treatment (MAT)?
  • Are you willing to limit smoking to outside the residential facilities?
  • Are you willing to stop using alcohol for the duration of your stay?
  • Are you willing to stop using drugs (other than verified prescriptions) for the duration of your stay?
  • Have you ever drank alcohol to excess?
  • Have you ever overdosed on legal substances (prescription medication)?
  • Have you ever overdosed on illegal substances?
  • Do you believe you are addicted to any substances?
  • Do alcohol / drug use and sexual activities go together for you?
  • Has your alcohol use caused a reduction in your sex drive or produced an inability to function sexually?
  • Which do you consider more difficult to control?
  • Are you currently receiving medical treatment for addiction?
  • Are you currently participating in AA / NA meetings?

  • V. Relationship History

  • Have you ever been a victim of psychological abuse?
  • Have you ever been a victim of stalking?
  • Have you ever been a victim of physical abuse?
  • Have you ever been hurt in a sexual way?
  • Do you have an active restraining order against an individual?
  • Is there any aspect of your sexual behavior that concerns you?
  • Have you ever exchanged sex for money?
  • Have you ever exchanged sex for other tangible items (e.g. drugs, clothing, housing, food, etc.)?
  • Have you ever exchanged sex for security or a place to sleep?
  • Did it happen in other states?
  • Have you ever been forced into the sex industry by a pimp, trafficker, or family member?
  • Have you ever been in a relationship with a pimp?
  • Have you ever attempted to leave the lifestyle?
  • Have you experienced emotional difficulties related to your sexual exploitation?
  • Have you received an STD test in the last two months?
  • Do you currently have an STD?
  • If YES, are you being treated for it?
  • If you are accepted into the Residential Program, will you be able to self-administer your treatment / medication?

  • VI. Mental Health Information

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  • Have you ever attempted suicide?
  • Do you ever feel that you would like to injure yourself?
  • Do you ever feel that you would like to injure others?
  • Are you depressed at this time?
  • Have you received a Mental Health Diagnosis?
  • Are you currently receiving medical treatment for mental health?
  • Are you currently taking medications for your mental health?
  • Have you ever been hospitalized for psychiatric illness or treated for a psychiatric problem?
  • Do you feel you have psychiatric problems at this time?

  • VII. Physical Health Information

  • Are you experiencing current medical problems?
  • Are you experiencing current dental problems?
  • Do you feel you need medical treatment at this time?
  • Are you pregnant?
  • Do you wear glasses / contacts?
  • Do you have any physical disabilities?
  • Do you have any speech problems?
  • Do you have any hearing problems?
  • Do you have health insurance?
  • Have you filed for Social Security or Social Security Disability?

  • VIII. Criminal Justice/Incarceration Information

  • If you are currently incarcerated, please answer the following:

  • If you are not currently incarcerated, please answer the following:

  • On Probation?
  • On Parole?
  • Diversion program?
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  • Do you have any active warrants?
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  • You MUST click the Submit to record your application.  A staff member from Oasis House will be in contact with you soon.

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