Resident Application Form

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Admission Criteria

Our application takes a while to get through - plan on 45-60 minutes. Technical issues do happen, so we encourage you to create a login to save your application as you work so that you can come back to it later and have a copy should technical issues occur.

  • Women over the age of 18 who are survivors of human sex trafficking.

  • Potential residents must:

  • Express a desire to commit to the program and to their treatment and healing. 

  • Be ambulatory.

  • Be able to perform basic self-help activities, such as eating and bathing.  

  • Have the ability to care for their own possessions to maintain bedroom and living area in a reasonable state of orderliness and cleanliness.

  • Be able to recognize danger or threat to personal safety.

  • Have the ability to live comfortably within any limitations in the structure of the facility.

  • Be generally able to maintain appropriate behaviors tolerable to the community.

  • Be willing to submit to and pass regular and random drug testing.

  • Have already received emergent care, as we are not an emergency/temporary shelter and we are not a detoxification facility.

  • Sign all required documents upon intake.

  • RSM is unable to provide services for women who are severely hearing impaired or severely visually impaired.  

  • RSM is unable to provide services to women with outstanding warrants.

  • RSM is unable to provide services to women who are registered sex offenders.

  • RSM is unable to admit women who are currently using or abusing substances.  Residents with such a history must already be in recovery and have 30 days clean in order to be considered for admittance into RSM. Residents must pass a drug screen at intake.

  • RSM may not be equipped to provide the necessary care for women with severe and/or pervasive mental illness.  Potential residents will be asked to disclose their mental health history, including prior counseling, diagnoses, medications, and hospitalizations.  All admittance decisions will be made on a case by case basis by RSM staff.

  • Potential residents will be asked to disclose any medical conditions, as RSM may not be equipped to adequately assist individuals with severe health/medical conditions.

  • RSM is unable to admit women who are currently pregnant.  A pregnancy test will be conducted at intake.

  • Women who currently have custody of their child(ren) must make provisions for their child(ren) to be in temporary custody with a trusted party while at RSM.  RSM is willing to assist in this process.  RSM will assist in making arrangements for approved visitations with child(ren).  

  • A fully completed application is required.  Incomplete applications will not be considered. Women will be asked to disclose information regarding their history and experience, including substance abuse and mental health information, in order for staff to determine if RSM is able to best meet their needs.  Once the application is submitted, staff will thoroughly review it to determine the potential resident’s eligibility for the program.  If it is determined that the applicant meets initial criteria, an applicant interview will be conducted to determine if RSM is an appropriate fit.  If a decision is reached to invite the applicant into the program, the applicant will then be contacted by RSM staff for additional instructions regarding the move in process.  If not admitted to the program, appropriate referrals will be given.  Throughout this process, RSM staff will make every effort to provide follow-up and feedback in a timely manner.

  • Background checks will be done on all who apply to the RSM program.

  • Providing false information on this application may result in dismissal from the RSM program.

  • In order to provide the best care possible, RSM reserves the right to use discretion when making admission decisions.  

Personal Information





Format: mm/dd/yyy








Current Address Information





Communication Information







Current Situation



Relationship History





Dependent Information








Education and Employment

Employment Information







Education Information








Trafficking / Prostitution History



Coercion








Trafficking Information









Trafficker Information




Abuse Information - As an Adult
Have you ever been subject to the following as an adult?







Abuse Information - As a Child
Have you ever been subject to the following as an child?







Trauma-Based Program

Programs




Drug and Alcohol History
















Drug Information
Which drug(s) do you, or did you, frequently use? How often? Method of use (IV, snort, smoke, oral)?






























Substance Use Treatment

Information







Medical History and Information







Medications
Please list any prescribed medications for your physical health you are currently taking or have taken in the last six months.


























Testing
Have you ever been tested for any of the following?

























Mental Health Status




















Mental Health Medications








Legal Information












































Goals, Needs, Strengths, and Interests










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