5(1(:$/ +286( intake ap3lication form
TRANSCRIPT
Microsoft Word - AMETHYST HOUSE INTAKE
SCREENING.DOC6REHU/LYLQJ7KURXJK5HODWLRQVKLSZLWK-HVXV&KULVW
9LFNVEXUJ06 Phone:
Educating Our Community * Saving Our Families * Proving 5HFRYHU\Works
5(1(:$/+286( INTAKE AP3LICATION FORM General Information: (PLEASE PRINT)
Name: (Last) ___________________________ (First) ___________________________ (MI) _________________
Street: _________________________________ City: ____________________ State: ______ Zip: _____________
Birth Date: _____/_____/_____ Ethnic Background: ____________ Marital Status: __________________
Home#: ____ - ____ - _________ Cell #: _____ - _____ - _________ Alt. #: _____ - _____ - _________
Name: ___________________________ Relation: _______________ Tel: ____ - ____ - _____
Name: __________________________ Relation: _______________ Tel: ____ - ____ - _____
Status: (PLEASE PRINT)
Veteran: __Y __ N (Branch: ______________) Referred By_: ___ ______________________________
Are you on: Probation: ____ Y, ____N DHS Involved: ____Y, ____N Court Involved: ____ Y, ____N
DHSCW, PO, Etc.. Name: _______________________________________ Phone #: _______ - _______ - _________
Lived at Sober Living Home before? _________ When/Where? _________________________________
Physical Condition at Entry: ________________________________________________________________________
Emotional/Mental Condition at Entry: _______________________________________________________________
Medication(s): _______________, ________________, _______________, _______________, _________________.
Drug(s) of Choice: _______________, _______________, _______________, _______________, _______________.
Most Recent Drug(s) Used: (including Alcohol) ______________, _______________ Date of last Use? ____________
1. What is your first and second drug of choice? ____________________________, __________________________
2. How old were you when you first used drugs/drank? ________________________________________________
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Educating Our Community * Saving Our Families * Proving 5HFRYHU\Works
3. Have you ever been in a D/A Treatment Center? ___ Y, ___ N Where/When? ____________________________
4. Have you ever been in a halfway house? ___ Y, ___ N Where/When? __________________________________
5. What is your highest level of education?
_____High School Graduate _____College/University
_____GED _____Other (Please explain) _______________________________
6. Have you ever been in prison? ___ Y, ___ N Where/When? ____________________________ # of times? _____
7. Have you ever been ARRESTED for a sex crime or arson? YES______ NO ______, When? _________________
8. Where did you live in before moving here? (Place/City/State) __________________________________________
9. Are you employed? If yes, what kind of work do you do? _____________________________________________
10. What are your means of transportation? __________________________________________________________
11. What is your source of income? ________________________________________________________________
12. (Check ONE): Are you _________ Married __________ Single _________ Divorced _________Separated
13. Have you ever received any DUI's or DWI's? Yes ________No ________If yes, how many________
14. What kind of problems has drinking and/or drug use caused you? _______________________________________
15. Do you have any problems with rules or authority? __________________________________________________
16. Are you prejudiced towards any ethnic group or race? _________________________________________________
17. What kind of medical problems (physical) have you been or are you being treated for? ______________________ _______________________________________________________________________________________________
18. What kind of psychological problems (emotional) have you been or are you being treated for? ________________ _______________________________________________________________________________________________
19. Have you ever considered suicide? ____Y ____ N If so, how long ago ____, Did you have a Plan? ____ Y ____ N
20. If you answered yes to question #18, did you seek counseling or get help at that time? _____ Y _____ N
21. Are you having any thoughts of harming your self now? ____ Y ____ N
(If you answered “yes” to any of the above, were you under the influence at the time? ____ Y ____ N)
By signing below I am stating that my answers to the above questions have been truthful and accurate and understand that if I have been dishonest in any of my responses I could be evicted from the house.
PRINT NAME: ______________________________________________________________________________
SIGNATURE: _____________________________________________ DATE: ______________________
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Educating Our Community * Saving Our Families * Proving 5HFRYHU\ Works
5(1(:$/+286( NEEDS SCREENING FORM In Your Own Words:
I need help with the following:
____ Housing Medical Care Education Hygiene Cleaning ____ Paying )HHV/Utilities
____ Shopping & Meal Preparations ____ Mental Health Services
____ Substance Abuse Services ____ Health and Wellness Services
____ Securing Benefits ____ Money/Debt Management
____ Legal Assistance ____ Relapse Prevention
Do you attend AA/NA? ____ Y ____ N When/Where did you last attend? __________________________________
What do you think is your biggest or most challenging issue? _____________________________________________
Are you interested in maintaining a sober lifestyle? ____ Y ____ N ____ Not sure
What are the relapse triggers you can recognize? _______________________________________________________
What are your strengths? __________________________________________________________________________
What are the barriers to your goals? _________________________________________________________________
What specific assistance or support would best help you to reach these goals? ________________________________
Is there anything else you can tell us about yourself that would assist us in helping you meet your goals? ___________ _______________________________________________________________________________________________
PRINT NAME: ______________________________________________________________________________
SIGNATURE: _____________________________________________ DATE: ______________________
ZEt>,Kh^RULES,REQUIREMENTS,PROCEDURES,ANDHOUSEMEMBERAGREEMENT (revised11/11)
Youmustbefamiliarwith,andcomplywith,theseHouseRules.
MISSIONSTATEMENT: ZHousehasamissiontobeoneofthepremierprovidersofsoberlivinghousinginbyprovidinganalcoholand drugfreeresidenceinaclean,safe,supportiveenvironmentandrecoverysupportservicestoeachofitshouse members.Housememberswillbeadultalcoholicsandaddictswhoaremotivatedto continuetheirrecovery,committedtostayingsober,andagreetoremainactiveintheirrecoveryprogram.
SECTION1–PROSPECTIVEHOUSEMEMBERS: 1.1Qualifications–Tobeconsideredforadmittance,prospectivehousemembersshallpossessthefollowing:adesireto staysober,abilitytogetalongwithothers,agreetoabidebyallhouserules,abilitytofunctionwithinhousedemands andrequirements,soberforaminimumofdays(exceptionsmadeona1x1basis),awillingnesstoworktheir program,andtheabilitytomeetfinancialrequirements.
1.2Screening–,,D Z,W
1.3Applicationform–Acopyofthenewhousememberapplicationformmustbecompletedinitsentiretytobe consideredintoZHouse.ZEt>,Kh^reservestherighttocontactand/orverifyany referenceprovidedontheapplicationform.Acopyofthecompletedandsignedapplicationform,thesignedhouse agreement,criminalhistoryverificationform,andacopyofthehousemember’sphotoidentificationshallbeplacedin thehousemember’sfile.
1.4InitialFees,PaymentandMinimumLengthofStay–/ ,Ψ,Ψ ,Ψ/, Z,,/ ,,
Itisrecommendedifthehousememberhastheresourcesand/orability,thathe/shetrytopaytheirfirstmonth’shouse feesupfront.Rememberthathousefeesmustbepaidonorbeforetheyaredue(dueeveryFridayforthe followingweek).
ZHouserequiresaminimumstayof120daysandallowsamaximumstayuptomonth.Ifahousemember leavesthehouseontheirownpriortothe120daysorifahousememberleavesthehousepriortograduationoris evictedfromthehouseduetononpaymentorduetoaviolationofhouseruleswillberequiredtopayany remainingunpaidfeesRememberitiseachresidentsresponsibilitytoaskforareceiptforallandpayments. Allchecksaretobemadepayableto"Z,Η,withoutexceptions.
1.5Cleaning,MovingandStorageFees–Ifaresidentleavesthehouseprematurelyagainststaffadvice,is ormovesoutofZHouseanddoesnotimmediatelytaketheirpersonalpropertywiththemtheycanbe chargedapacking/cleanupfeeof$25.00andastoragefeeof$25.00(perday)tostoretheirbelongings.Ifpersonal belongingsarenotpickedupwithin10daysofaresidentmovingouttheymaybeforfeitedbytheresidentand donatedtoalocalcharitybyZ,staff.
SECTION2–RESIDENCYREQUIREMENTS: 2.1–AgreetonotdrinkalcoholoruseanyillicitdrugswhilelivingatZEt>,Kh^.Alsoagreenottohaveany alcohol,illegaldrugs,ordrugparaphernaliaonthepropertyatanytime.
2.2–Abilitytopassadrugandalcoholtestandagreetosubmittorandomtestingatanytime,knowingthatrefusingto testornotgivingasampleintheallottedtimewillresultina“refusaltotestandthesamplebeingconsideredpositive.
2.3– ZZ,
2.4–Respecttherights,viewsandpropertyofotherhousemembers,whilelearningtogetalongwithothers.
2.5–Agreetocontributetothecleanlinessofthehousebydoingassignedweeklychore(s)andpickingupafter themselves.
2.6–Agreetoabidebyallthehouserules.
2.7–Abilityandagreementtopay
2.8–Agreetotakeprescriptionmedicationsasprescribedandbeingoodmedicalhealth,freeofcommunicablediseases thatputothersatriskofcontractionthroughcasualcontact.Keepallmedicalandmentalhealthappointments.E Z,
2.9–Agreetonotdisplay,norwearanythingthatadvertisesalcoholbeverages,drugsorgangrelatedapparel.,
3.0–Agreetonotalloworcarryanyfireworks,firearms,knives,weapons,etc.inyourroomoranyplaceonoraround Amethystproperty.
SECTION3–HOUSERULES: Note:Z,staffreservestherighttochangeormakeadditionstothehouserulesatanytime.Z ,staffalsohastherighttointerpretandapplytherulesattheirowndiscretionandmaydosodifferentlyfromcase tocase.Theseruleshavebeenadoptedandmodifiedbythehouseandhousemembersoverthecourseof .TheserulesmustbeapprovedbytheZ,D.
3.1PolicyProhibitingAlcoholandNonPrescribedDrugs–Alcohol,illegaldrug,ornonprescribeddruguseorpossession arestrictlyprohibited.Procedureforsuspecteddrug/alcoholuseisasfollows:1)Aurinescreenwillberequestedby houseandZ,staffathousemembersexpense(ifthetestispositive).Anyhousememberwhois foundtohaveused,isundertheinfluenceof,orinpossessionsofalcoholorillicitdrugswillbeimmediatelyrequiredto moveout,followZ,staffrecommendationsandstayoutofthathouseforaminimumof30days.ALL HOUSEMEMBERSWILLBESUBJECTTORANDOMDRUGSCREENSand/orROOMSEARCHES.Undernocircumstances shallahousememberwhoisundertheinfluencebeallowedinthehouse.Z,staffshallpacktheirbagsfor them.Whensober,thehousemembercanarrangewithZ,officetoretrievepersonalproperty.
3.2PrescriptionDrugPolicy–Allprescriptionandoverthecountermedicationsbeingtakenmustbedisclosedto Z,staffpriortoadmissionsand/ortakingit(ifreceivedafterbeingadmittedtohouse).Itisthehouse members’responsibilitytonotifystaffwhenthereisachangetotheirmedications.Ifahousememberisprescribed psychotropicmedications,thehousemembermustcontinuetakingthemtostayinthehouse.Prescriptionmedications mustbetakeninthedosageandfrequencyasprescribed.Abuseofmedicationcanbeconsideredarelapse.Takingor possessingprescriptiondrugsthatareprescribedtosomeoneelseisprohibited.Keepallmedicalandmentalhealth appointments.Anyprescription(s)thatarenotallowedtobefilledinthehousemustbetakenandshreddedbyZ ,staffastherecanbenounfillednonapprovedprescriptionsinthehouse.
3.3Violence–s, z
3.4Curfew–CurfewsmustbefollowedunlessotherarrangementsaremadeinadvancewithZHouseRecovery SupportStafforD.
3.Television–TV'sareallowedinindividualsroomsdhehouseTVshallbeturnedoffby11:00pmdailyandby 1:00amSaturdayandSundaymorningsandshallremainoffuntilnoearlierthan6:00am.Duringtheweekdays, Monday–Friday,theTVshallbeofffrom9am4pm.ThehouseTVshallbesettothechannelwhichthemajorityof viewersselect.
3.Stereos–Personalstereosarepermittedinthehouseandmaybeplayedonlywiththeuseofheadphones.
3.Treatment/HouseMeetings–Participationintheweeklytreatmentgroupsandhousemeeting(s)aremandatory. Additionalmeetingsmaybecalledwhenasituationwarrants.Acceptablereasonsforexcusedabsencesarebeing hospitalizedorhavingtowork(paidwork,notvolunteering).
3.Cleaning–Alistofchoreswillbepostedweekly.Housemembersareexpectedtocompleteassignedchoresina timelyfashion.Choresshouldbecompletedby10amorpriortoleavingthehouse,orthenightbefore.Thecompletion ofchoresareverifiedbythehouse.BottledwaterONLYisallowedinthebedroomsandthelivingroom. Remembercleanlinessstartswithyourself,showerdaily,andkeepyourpersonallivingareacleanandorderly.Donot hanganythingonlamps,doors,doorknobs,furniture,orwallfixtures.Beconsiderateofyourroommatesandothers. Washyourclothesandbeddingregularly.Laundryhoursarefrom10:00amto10:00pm.
Housemembersareexpectedtopickupafterthemselvesandcleanappliancesafteruse.Dishes,cups,utensilsaretobe washedorloadedinthedishwasherimmediatelyafteruse.Personalbelongingsandtrashshallnotbeleftoutinthe house.
3.Bedrooms–Housemembersareexpectedtokeeptheirbedroomscleanandneatatalltimes.Bedsmustbemade eachmorning.OnMondaythroughFridayHousemembersareencouragedtobeupandoutofbedby8am.Onlythose residinginagivenroomandstaffmayenterthatroom.Z,staffhastherighttoenteranyroomatany time.Foodanddrinksarenottobestoredorconsumedinbedrooms.BottledwaterONLYisallowedinthebedrooms andthelivingroom
3.1Behavior–Housemembersareexpectedtoactlikegentlemen.Nopornographyorsexualactivityonpremises,no cussing,nofighting,nostealing,nolying,andnobehaviorthatisnotconducivetorecovery.Intimaterelationsbetween Housemembersarenotallowed.Thelivingroom,diningroom,kitchen,andyardarecommonareas.Rulesofcommon courtesy,respect,cleanliness,andcooperationareinorder.Housemembersareexpectedtobegoodneighbors,not just“nondisturbing”neighbors.Eachhousememberwillrespecteachotherandeachotherspropertysothebasicrules areifitdoesnotbelongtoyou,donotuseitortakeit.AskFirst!NOISELEVEL:Ifsomeoneispickingyouup,blowing theirhorntogetyourattentionisunacceptable.Becourteoustoallincludingyourroommates. TVandstereoincommonareasaretobekeptataminimumtobecourteoustootherTenantsthatmayberesting.Ifthe volumecanbeheardoutsideofthecommonarea,thenitistooloud.
3.1VisitationPolicy–Guestsareallowedinthehousebetweenthehoursof9:00amand10:00pm.Guestsmustabide byallhouserulesandareexpectedtobeclean,courteous,andsoberatalltimes.Guestsmaynotstayovernight.Guests mustbeescortedbythehosthousemember,whoisresponsiblefortheguestwhileinthehouse.Guestsarenotallowed inanybedroom.Guestswillberequiredtovacatethepropertyforanyviolationofhouserulesorprocedures.
3.1SmokingPolicy–Smokingisnotallowedinsidethehouseatanytime.Smokingisallowedoutsideindesignated areasprovidedthattheashesandbutsaredisposedofinthepropercontainers.d Z,
3.1CardinalRulesdZ, Any housememberrequestingtoreenterZHousewillhavetoberescreenedandreacceptedbyhouse membersandZ,staff.EZ, x Violenceorthreatofviolence x Refusaltoprovideortamperingwithurinesample x SexualActivityinthehouseorontheproperty x A"chronic"badattitude x Arson x Notstayingcurrentwith x Disruptive,threateningorabusivebehaviortowardotherhousemembersorSOSstaff x Possessingand/orusingalcoholand/ordrugs,abusingprescriptiondrugsorbeingintoxicated x Stealingordestructionofhouseproperty x Knowinglybreakinganylocal,stateorfederallaws x Notinformingstaffwhenanotherclientisusingalcoholordrugs
3.1,,
SECTION4–POLICY/GUIDELINES/PROCEDURES 4.1ChainofCommand–Allhousememberquestions,concernsandcommentsaretobedirectedtothehouse first,thentoHouseRecoverySupportStaff,beforebeingbroughttotheattentionofthe.
4.2ExceptionstoCurfew–Overnight/weekendpassesmaybegrantedatthediscretionofZ,staffifthe followingcriteriaaremet:
x TheHousememberhaslivedatthehouseformorethan30days. x TheHousememberiscurrentwith. x Theovernightpasssliphasbeenfilledoutinitsentiretyandsignedapprovalbythehousecaptainandoneof
theHouseSponsor/RecoverySupportStaff,priortotheday. x TheHousememberhasmadearrangementstohavehis/herchorecoveredwhileaway. x ItistheHousemember’sresponsibilitytoinformHouseD/RecoverySupportStaffiftheirwork
scheduledoesnotallowforcompliancewithcurfew.
4.3Moving–Housemembersmaymovetoadifferentbedwithintheirassignedroom,whenabedopensup,basedon seniority.^HouseD/Recovery SupportStaffmustapprovemovesbetweenrooms.MovesarebasedonthediscretionofHouseD/Recovery SupportStaff.
PersonalbelongingsabandonedbyhousemembersbecomethepropertyofZEt>,Kh^fordonationor distributiontohousemembers.Abandonedpersonalbelongingsmaybehelduptosevendays.Arrangementsshould bemadewithHouseD/RecoverySupportStaffintheofficetopickuppersonalbelongings.
4.4Valuables– ItisagainstourSoberLivingpolicyforatenanttolendortoborrowothertenants’belongingsor money.Ifyoudolendorborrowanything,youdosoatyourownrisk.ZHouseisnotresponsibleforhouse members’personalproperty.Bringingvaluablesintothehouseareatthehousemembers’ownrisk.Abandoned propertywillbekeforuptodays.Housemembersarerequiredtoarrangefortheclaimingofthispropertyduring thistime,orallpropertywillbedonatedbacktothehouseorcharity.
4.5Emergencies–Thepoliceshouldbecalledonlyinthecaseofrealemergencies.Call911formedicalemergencies.If possible,thehousecaptainandHouseD/RecoverySupportStaffshouldbeinformedfirst.
4.6MailEtiquette–Mailshallbegiventothehousecaptainfordistribution.Openingmailaddressedtoanotherperson isafederaloffenseandaviolationofhouserules.Anymailthatismarkedfromapersoninjailorprisonmustbepre approvedbystaffpriortoreceivingit.
4.7ComputerEtiquette–Rulesofcommoncourtesyapply.Nohousemembershallmonopolizethecomputer.The computershallnotbeusedforpornography,gamblingoranyillegalactivities.
4.8PhoneEtiquette–Rulesofcommoncourtesyapply.Nohousemembershallmonopolizethehousephone.The housephoneshallnotbeusedforanyinappropriateorillegalactivities.Housemembersareaskedtotakemessagesfor otherhousemembers.
4.9Events–PeriodiceventsmaybecosponsoredbyZHouseD/RecoverySupportStafforsponsoredby housemembers.Thesecanincludebarbecues,holidaydinners,etc.Housemembersponsoredeventsareallowedwith priorauthorizationfromtheoffice.
4.10LaundryEtiquette–Useappliancesatyourownrisk.ZHouseprovideslaundryfacilitiesasaconvenience anddoesnotassumeresponsibilityforanydamagetoclothingorloss.Pleasedonotoverloadmachines.Ironsmustbe unpluggedwhennotinuse.UseofWasherandDryerarepermittedduringpostedtimes.Allhousemembersmustbe attentivetotheirlaundryandmaynotleavetheirlaundryinthemachinesformorethan15minutesafterthecyclehas beencompleted.ZHouseisnotresponsibleforlostvaluablesorcash.
4.11HouseFees–Housearetobepaidinadvanceandarenonrefundable.&dueeachweek(usually&riday before)oronthefirstofeachmonth(ifpayingentiremonth)unlessotherarrangementswiththedirectoraremadein advance.Ahousemembermaynotgetmorethan1weekbehindortheywillbeaskedtoleavethehouseItisthe Housemembers’responsibilitytocontactthedirectortomakepaymentortomakearrangementsforpayment.Z ,Dhasfinalauthorityregardingpaymentplans.
Itisyourresponsibilitytoaskforareceiptforallpayments.Allchecksaretobemadepayableto"Z,", withoutexceptions.
4.12Relapse–AHousememberwhorelapses(usesalcoholordrugs)willbeaskedtoimmediatelyvacatethehouse,and maynotmovebackintothathouseforaminimumofdays,uponwhichtimethehousemembermayreapplytothe house,participateinarescreeningandseeiftheywillbereacceptedbytheotherhousemembers.
4.1FireandTornadoSafetyReadandunderstandthepostedinformationonFireandTornado.Youmustbecome familiarwiththedesignatedescaperoutes,safegatheringlocationsandtheneedforasafelocationheadcount.Fireand tornadodrillswillbeconductedatregularintervals.Firepreventioniseveryone’sconcernandresponsibility.Practice safehabits,smokeonlyindesignatedareas,andbeawareofthefireextinguisherlocations,andhowtousethemfor smallfiresonly.Knowhowandwhentocall911.Emergencyinformationandaheadcountin/outboardarepostednear thefrontdoor.
4.1AutomobilesonthePropertyDriversmustbelicensedandinsured.Carsmusthavecurrentregistration.Auto repaironthepremisesisnotpermittedwithoutstaffpermission.d, ,
4.1Confidentiality–Z,^>& ,Z, d/
4.1SuccessfulCompletions–AnyhousememberthatsuccessfullycompletesZHousewillreceivetheir $1.00“sobriety”depositbacklessanymoniesneededtomakeanyrepairstoanyitemsorpartsofthehousesoiled, damagedorbrokenbythehousememberand/oranyguestsofthehousemember.Iftheamountnecessarytocleanor repairthedamageditemsorareaexceedsthe“sobriety”depositthenthehousememberwillberesponsibleforthe difference.Successfulcompletionisdefinedascompletingataminimum1)theminimumtimeframeofthehouse(3 months),2)completingtransitionphaserequirements(minimumof1month),and3)participateinhousegraduation ceremony.
BysigningbelowIacknowledgethatIhavereadandunderstandalloftherules,requirementsandpolicieslistedaboveand understandthatNONADHERENCETOTHESERULES/RESPONSIBILITIESCANBECAUSEFORIMMEDIATE/^,Z'.
HouseMembersSignature:__________________________________________
StaffSignature:_________________________________________________
Educating Our Community * Saving Our Families * Proving 5HFRYHU\Works
5(1(:$/+286( INTAKE AP3LICATION FORM General Information: (PLEASE PRINT)
Name: (Last) ___________________________ (First) ___________________________ (MI) _________________
Street: _________________________________ City: ____________________ State: ______ Zip: _____________
Birth Date: _____/_____/_____ Ethnic Background: ____________ Marital Status: __________________
Home#: ____ - ____ - _________ Cell #: _____ - _____ - _________ Alt. #: _____ - _____ - _________
Name: ___________________________ Relation: _______________ Tel: ____ - ____ - _____
Name: __________________________ Relation: _______________ Tel: ____ - ____ - _____
Status: (PLEASE PRINT)
Veteran: __Y __ N (Branch: ______________) Referred By_: ___ ______________________________
Are you on: Probation: ____ Y, ____N DHS Involved: ____Y, ____N Court Involved: ____ Y, ____N
DHSCW, PO, Etc.. Name: _______________________________________ Phone #: _______ - _______ - _________
Lived at Sober Living Home before? _________ When/Where? _________________________________
Physical Condition at Entry: ________________________________________________________________________
Emotional/Mental Condition at Entry: _______________________________________________________________
Medication(s): _______________, ________________, _______________, _______________, _________________.
Drug(s) of Choice: _______________, _______________, _______________, _______________, _______________.
Most Recent Drug(s) Used: (including Alcohol) ______________, _______________ Date of last Use? ____________
1. What is your first and second drug of choice? ____________________________, __________________________
2. How old were you when you first used drugs/drank? ________________________________________________
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Educating Our Community * Saving Our Families * Proving 5HFRYHU\Works
3. Have you ever been in a D/A Treatment Center? ___ Y, ___ N Where/When? ____________________________
4. Have you ever been in a halfway house? ___ Y, ___ N Where/When? __________________________________
5. What is your highest level of education?
_____High School Graduate _____College/University
_____GED _____Other (Please explain) _______________________________
6. Have you ever been in prison? ___ Y, ___ N Where/When? ____________________________ # of times? _____
7. Have you ever been ARRESTED for a sex crime or arson? YES______ NO ______, When? _________________
8. Where did you live in before moving here? (Place/City/State) __________________________________________
9. Are you employed? If yes, what kind of work do you do? _____________________________________________
10. What are your means of transportation? __________________________________________________________
11. What is your source of income? ________________________________________________________________
12. (Check ONE): Are you _________ Married __________ Single _________ Divorced _________Separated
13. Have you ever received any DUI's or DWI's? Yes ________No ________If yes, how many________
14. What kind of problems has drinking and/or drug use caused you? _______________________________________
15. Do you have any problems with rules or authority? __________________________________________________
16. Are you prejudiced towards any ethnic group or race? _________________________________________________
17. What kind of medical problems (physical) have you been or are you being treated for? ______________________ _______________________________________________________________________________________________
18. What kind of psychological problems (emotional) have you been or are you being treated for? ________________ _______________________________________________________________________________________________
19. Have you ever considered suicide? ____Y ____ N If so, how long ago ____, Did you have a Plan? ____ Y ____ N
20. If you answered yes to question #18, did you seek counseling or get help at that time? _____ Y _____ N
21. Are you having any thoughts of harming your self now? ____ Y ____ N
(If you answered “yes” to any of the above, were you under the influence at the time? ____ Y ____ N)
By signing below I am stating that my answers to the above questions have been truthful and accurate and understand that if I have been dishonest in any of my responses I could be evicted from the house.
PRINT NAME: ______________________________________________________________________________
SIGNATURE: _____________________________________________ DATE: ______________________
6REHU/LYLQJ7KURXJK5HODWLRQVKLSZLWK-HVXV&KULVW 9LFNVEXUJ063KRQH
Educating Our Community * Saving Our Families * Proving 5HFRYHU\ Works
5(1(:$/+286( NEEDS SCREENING FORM In Your Own Words:
I need help with the following:
____ Housing Medical Care Education Hygiene Cleaning ____ Paying )HHV/Utilities
____ Shopping & Meal Preparations ____ Mental Health Services
____ Substance Abuse Services ____ Health and Wellness Services
____ Securing Benefits ____ Money/Debt Management
____ Legal Assistance ____ Relapse Prevention
Do you attend AA/NA? ____ Y ____ N When/Where did you last attend? __________________________________
What do you think is your biggest or most challenging issue? _____________________________________________
Are you interested in maintaining a sober lifestyle? ____ Y ____ N ____ Not sure
What are the relapse triggers you can recognize? _______________________________________________________
What are your strengths? __________________________________________________________________________
What are the barriers to your goals? _________________________________________________________________
What specific assistance or support would best help you to reach these goals? ________________________________
Is there anything else you can tell us about yourself that would assist us in helping you meet your goals? ___________ _______________________________________________________________________________________________
PRINT NAME: ______________________________________________________________________________
SIGNATURE: _____________________________________________ DATE: ______________________
ZEt>,Kh^RULES,REQUIREMENTS,PROCEDURES,ANDHOUSEMEMBERAGREEMENT (revised11/11)
Youmustbefamiliarwith,andcomplywith,theseHouseRules.
MISSIONSTATEMENT: ZHousehasamissiontobeoneofthepremierprovidersofsoberlivinghousinginbyprovidinganalcoholand drugfreeresidenceinaclean,safe,supportiveenvironmentandrecoverysupportservicestoeachofitshouse members.Housememberswillbeadultalcoholicsandaddictswhoaremotivatedto continuetheirrecovery,committedtostayingsober,andagreetoremainactiveintheirrecoveryprogram.
SECTION1–PROSPECTIVEHOUSEMEMBERS: 1.1Qualifications–Tobeconsideredforadmittance,prospectivehousemembersshallpossessthefollowing:adesireto staysober,abilitytogetalongwithothers,agreetoabidebyallhouserules,abilitytofunctionwithinhousedemands andrequirements,soberforaminimumofdays(exceptionsmadeona1x1basis),awillingnesstoworktheir program,andtheabilitytomeetfinancialrequirements.
1.2Screening–,,D Z,W
1.3Applicationform–Acopyofthenewhousememberapplicationformmustbecompletedinitsentiretytobe consideredintoZHouse.ZEt>,Kh^reservestherighttocontactand/orverifyany referenceprovidedontheapplicationform.Acopyofthecompletedandsignedapplicationform,thesignedhouse agreement,criminalhistoryverificationform,andacopyofthehousemember’sphotoidentificationshallbeplacedin thehousemember’sfile.
1.4InitialFees,PaymentandMinimumLengthofStay–/ ,Ψ,Ψ ,Ψ/, Z,,/ ,,
Itisrecommendedifthehousememberhastheresourcesand/orability,thathe/shetrytopaytheirfirstmonth’shouse feesupfront.Rememberthathousefeesmustbepaidonorbeforetheyaredue(dueeveryFridayforthe followingweek).
ZHouserequiresaminimumstayof120daysandallowsamaximumstayuptomonth.Ifahousemember leavesthehouseontheirownpriortothe120daysorifahousememberleavesthehousepriortograduationoris evictedfromthehouseduetononpaymentorduetoaviolationofhouseruleswillberequiredtopayany remainingunpaidfeesRememberitiseachresidentsresponsibilitytoaskforareceiptforallandpayments. Allchecksaretobemadepayableto"Z,Η,withoutexceptions.
1.5Cleaning,MovingandStorageFees–Ifaresidentleavesthehouseprematurelyagainststaffadvice,is ormovesoutofZHouseanddoesnotimmediatelytaketheirpersonalpropertywiththemtheycanbe chargedapacking/cleanupfeeof$25.00andastoragefeeof$25.00(perday)tostoretheirbelongings.Ifpersonal belongingsarenotpickedupwithin10daysofaresidentmovingouttheymaybeforfeitedbytheresidentand donatedtoalocalcharitybyZ,staff.
SECTION2–RESIDENCYREQUIREMENTS: 2.1–AgreetonotdrinkalcoholoruseanyillicitdrugswhilelivingatZEt>,Kh^.Alsoagreenottohaveany alcohol,illegaldrugs,ordrugparaphernaliaonthepropertyatanytime.
2.2–Abilitytopassadrugandalcoholtestandagreetosubmittorandomtestingatanytime,knowingthatrefusingto testornotgivingasampleintheallottedtimewillresultina“refusaltotestandthesamplebeingconsideredpositive.
2.3– ZZ,
2.4–Respecttherights,viewsandpropertyofotherhousemembers,whilelearningtogetalongwithothers.
2.5–Agreetocontributetothecleanlinessofthehousebydoingassignedweeklychore(s)andpickingupafter themselves.
2.6–Agreetoabidebyallthehouserules.
2.7–Abilityandagreementtopay
2.8–Agreetotakeprescriptionmedicationsasprescribedandbeingoodmedicalhealth,freeofcommunicablediseases thatputothersatriskofcontractionthroughcasualcontact.Keepallmedicalandmentalhealthappointments.E Z,
2.9–Agreetonotdisplay,norwearanythingthatadvertisesalcoholbeverages,drugsorgangrelatedapparel.,
3.0–Agreetonotalloworcarryanyfireworks,firearms,knives,weapons,etc.inyourroomoranyplaceonoraround Amethystproperty.
SECTION3–HOUSERULES: Note:Z,staffreservestherighttochangeormakeadditionstothehouserulesatanytime.Z ,staffalsohastherighttointerpretandapplytherulesattheirowndiscretionandmaydosodifferentlyfromcase tocase.Theseruleshavebeenadoptedandmodifiedbythehouseandhousemembersoverthecourseof .TheserulesmustbeapprovedbytheZ,D.
3.1PolicyProhibitingAlcoholandNonPrescribedDrugs–Alcohol,illegaldrug,ornonprescribeddruguseorpossession arestrictlyprohibited.Procedureforsuspecteddrug/alcoholuseisasfollows:1)Aurinescreenwillberequestedby houseandZ,staffathousemembersexpense(ifthetestispositive).Anyhousememberwhois foundtohaveused,isundertheinfluenceof,orinpossessionsofalcoholorillicitdrugswillbeimmediatelyrequiredto moveout,followZ,staffrecommendationsandstayoutofthathouseforaminimumof30days.ALL HOUSEMEMBERSWILLBESUBJECTTORANDOMDRUGSCREENSand/orROOMSEARCHES.Undernocircumstances shallahousememberwhoisundertheinfluencebeallowedinthehouse.Z,staffshallpacktheirbagsfor them.Whensober,thehousemembercanarrangewithZ,officetoretrievepersonalproperty.
3.2PrescriptionDrugPolicy–Allprescriptionandoverthecountermedicationsbeingtakenmustbedisclosedto Z,staffpriortoadmissionsand/ortakingit(ifreceivedafterbeingadmittedtohouse).Itisthehouse members’responsibilitytonotifystaffwhenthereisachangetotheirmedications.Ifahousememberisprescribed psychotropicmedications,thehousemembermustcontinuetakingthemtostayinthehouse.Prescriptionmedications mustbetakeninthedosageandfrequencyasprescribed.Abuseofmedicationcanbeconsideredarelapse.Takingor possessingprescriptiondrugsthatareprescribedtosomeoneelseisprohibited.Keepallmedicalandmentalhealth appointments.Anyprescription(s)thatarenotallowedtobefilledinthehousemustbetakenandshreddedbyZ ,staffastherecanbenounfillednonapprovedprescriptionsinthehouse.
3.3Violence–s, z
3.4Curfew–CurfewsmustbefollowedunlessotherarrangementsaremadeinadvancewithZHouseRecovery SupportStafforD.
3.Television–TV'sareallowedinindividualsroomsdhehouseTVshallbeturnedoffby11:00pmdailyandby 1:00amSaturdayandSundaymorningsandshallremainoffuntilnoearlierthan6:00am.Duringtheweekdays, Monday–Friday,theTVshallbeofffrom9am4pm.ThehouseTVshallbesettothechannelwhichthemajorityof viewersselect.
3.Stereos–Personalstereosarepermittedinthehouseandmaybeplayedonlywiththeuseofheadphones.
3.Treatment/HouseMeetings–Participationintheweeklytreatmentgroupsandhousemeeting(s)aremandatory. Additionalmeetingsmaybecalledwhenasituationwarrants.Acceptablereasonsforexcusedabsencesarebeing hospitalizedorhavingtowork(paidwork,notvolunteering).
3.Cleaning–Alistofchoreswillbepostedweekly.Housemembersareexpectedtocompleteassignedchoresina timelyfashion.Choresshouldbecompletedby10amorpriortoleavingthehouse,orthenightbefore.Thecompletion ofchoresareverifiedbythehouse.BottledwaterONLYisallowedinthebedroomsandthelivingroom. Remembercleanlinessstartswithyourself,showerdaily,andkeepyourpersonallivingareacleanandorderly.Donot hanganythingonlamps,doors,doorknobs,furniture,orwallfixtures.Beconsiderateofyourroommatesandothers. Washyourclothesandbeddingregularly.Laundryhoursarefrom10:00amto10:00pm.
Housemembersareexpectedtopickupafterthemselvesandcleanappliancesafteruse.Dishes,cups,utensilsaretobe washedorloadedinthedishwasherimmediatelyafteruse.Personalbelongingsandtrashshallnotbeleftoutinthe house.
3.Bedrooms–Housemembersareexpectedtokeeptheirbedroomscleanandneatatalltimes.Bedsmustbemade eachmorning.OnMondaythroughFridayHousemembersareencouragedtobeupandoutofbedby8am.Onlythose residinginagivenroomandstaffmayenterthatroom.Z,staffhastherighttoenteranyroomatany time.Foodanddrinksarenottobestoredorconsumedinbedrooms.BottledwaterONLYisallowedinthebedrooms andthelivingroom
3.1Behavior–Housemembersareexpectedtoactlikegentlemen.Nopornographyorsexualactivityonpremises,no cussing,nofighting,nostealing,nolying,andnobehaviorthatisnotconducivetorecovery.Intimaterelationsbetween Housemembersarenotallowed.Thelivingroom,diningroom,kitchen,andyardarecommonareas.Rulesofcommon courtesy,respect,cleanliness,andcooperationareinorder.Housemembersareexpectedtobegoodneighbors,not just“nondisturbing”neighbors.Eachhousememberwillrespecteachotherandeachotherspropertysothebasicrules areifitdoesnotbelongtoyou,donotuseitortakeit.AskFirst!NOISELEVEL:Ifsomeoneispickingyouup,blowing theirhorntogetyourattentionisunacceptable.Becourteoustoallincludingyourroommates. TVandstereoincommonareasaretobekeptataminimumtobecourteoustootherTenantsthatmayberesting.Ifthe volumecanbeheardoutsideofthecommonarea,thenitistooloud.
3.1VisitationPolicy–Guestsareallowedinthehousebetweenthehoursof9:00amand10:00pm.Guestsmustabide byallhouserulesandareexpectedtobeclean,courteous,andsoberatalltimes.Guestsmaynotstayovernight.Guests mustbeescortedbythehosthousemember,whoisresponsiblefortheguestwhileinthehouse.Guestsarenotallowed inanybedroom.Guestswillberequiredtovacatethepropertyforanyviolationofhouserulesorprocedures.
3.1SmokingPolicy–Smokingisnotallowedinsidethehouseatanytime.Smokingisallowedoutsideindesignated areasprovidedthattheashesandbutsaredisposedofinthepropercontainers.d Z,
3.1CardinalRulesdZ, Any housememberrequestingtoreenterZHousewillhavetoberescreenedandreacceptedbyhouse membersandZ,staff.EZ, x Violenceorthreatofviolence x Refusaltoprovideortamperingwithurinesample x SexualActivityinthehouseorontheproperty x A"chronic"badattitude x Arson x Notstayingcurrentwith x Disruptive,threateningorabusivebehaviortowardotherhousemembersorSOSstaff x Possessingand/orusingalcoholand/ordrugs,abusingprescriptiondrugsorbeingintoxicated x Stealingordestructionofhouseproperty x Knowinglybreakinganylocal,stateorfederallaws x Notinformingstaffwhenanotherclientisusingalcoholordrugs
3.1,,
SECTION4–POLICY/GUIDELINES/PROCEDURES 4.1ChainofCommand–Allhousememberquestions,concernsandcommentsaretobedirectedtothehouse first,thentoHouseRecoverySupportStaff,beforebeingbroughttotheattentionofthe.
4.2ExceptionstoCurfew–Overnight/weekendpassesmaybegrantedatthediscretionofZ,staffifthe followingcriteriaaremet:
x TheHousememberhaslivedatthehouseformorethan30days. x TheHousememberiscurrentwith. x Theovernightpasssliphasbeenfilledoutinitsentiretyandsignedapprovalbythehousecaptainandoneof
theHouseSponsor/RecoverySupportStaff,priortotheday. x TheHousememberhasmadearrangementstohavehis/herchorecoveredwhileaway. x ItistheHousemember’sresponsibilitytoinformHouseD/RecoverySupportStaffiftheirwork
scheduledoesnotallowforcompliancewithcurfew.
4.3Moving–Housemembersmaymovetoadifferentbedwithintheirassignedroom,whenabedopensup,basedon seniority.^HouseD/Recovery SupportStaffmustapprovemovesbetweenrooms.MovesarebasedonthediscretionofHouseD/Recovery SupportStaff.
PersonalbelongingsabandonedbyhousemembersbecomethepropertyofZEt>,Kh^fordonationor distributiontohousemembers.Abandonedpersonalbelongingsmaybehelduptosevendays.Arrangementsshould bemadewithHouseD/RecoverySupportStaffintheofficetopickuppersonalbelongings.
4.4Valuables– ItisagainstourSoberLivingpolicyforatenanttolendortoborrowothertenants’belongingsor money.Ifyoudolendorborrowanything,youdosoatyourownrisk.ZHouseisnotresponsibleforhouse members’personalproperty.Bringingvaluablesintothehouseareatthehousemembers’ownrisk.Abandoned propertywillbekeforuptodays.Housemembersarerequiredtoarrangefortheclaimingofthispropertyduring thistime,orallpropertywillbedonatedbacktothehouseorcharity.
4.5Emergencies–Thepoliceshouldbecalledonlyinthecaseofrealemergencies.Call911formedicalemergencies.If possible,thehousecaptainandHouseD/RecoverySupportStaffshouldbeinformedfirst.
4.6MailEtiquette–Mailshallbegiventothehousecaptainfordistribution.Openingmailaddressedtoanotherperson isafederaloffenseandaviolationofhouserules.Anymailthatismarkedfromapersoninjailorprisonmustbepre approvedbystaffpriortoreceivingit.
4.7ComputerEtiquette–Rulesofcommoncourtesyapply.Nohousemembershallmonopolizethecomputer.The computershallnotbeusedforpornography,gamblingoranyillegalactivities.
4.8PhoneEtiquette–Rulesofcommoncourtesyapply.Nohousemembershallmonopolizethehousephone.The housephoneshallnotbeusedforanyinappropriateorillegalactivities.Housemembersareaskedtotakemessagesfor otherhousemembers.
4.9Events–PeriodiceventsmaybecosponsoredbyZHouseD/RecoverySupportStafforsponsoredby housemembers.Thesecanincludebarbecues,holidaydinners,etc.Housemembersponsoredeventsareallowedwith priorauthorizationfromtheoffice.
4.10LaundryEtiquette–Useappliancesatyourownrisk.ZHouseprovideslaundryfacilitiesasaconvenience anddoesnotassumeresponsibilityforanydamagetoclothingorloss.Pleasedonotoverloadmachines.Ironsmustbe unpluggedwhennotinuse.UseofWasherandDryerarepermittedduringpostedtimes.Allhousemembersmustbe attentivetotheirlaundryandmaynotleavetheirlaundryinthemachinesformorethan15minutesafterthecyclehas beencompleted.ZHouseisnotresponsibleforlostvaluablesorcash.
4.11HouseFees–Housearetobepaidinadvanceandarenonrefundable.&dueeachweek(usually&riday before)oronthefirstofeachmonth(ifpayingentiremonth)unlessotherarrangementswiththedirectoraremadein advance.Ahousemembermaynotgetmorethan1weekbehindortheywillbeaskedtoleavethehouseItisthe Housemembers’responsibilitytocontactthedirectortomakepaymentortomakearrangementsforpayment.Z ,Dhasfinalauthorityregardingpaymentplans.
Itisyourresponsibilitytoaskforareceiptforallpayments.Allchecksaretobemadepayableto"Z,", withoutexceptions.
4.12Relapse–AHousememberwhorelapses(usesalcoholordrugs)willbeaskedtoimmediatelyvacatethehouse,and maynotmovebackintothathouseforaminimumofdays,uponwhichtimethehousemembermayreapplytothe house,participateinarescreeningandseeiftheywillbereacceptedbytheotherhousemembers.
4.1FireandTornadoSafetyReadandunderstandthepostedinformationonFireandTornado.Youmustbecome familiarwiththedesignatedescaperoutes,safegatheringlocationsandtheneedforasafelocationheadcount.Fireand tornadodrillswillbeconductedatregularintervals.Firepreventioniseveryone’sconcernandresponsibility.Practice safehabits,smokeonlyindesignatedareas,andbeawareofthefireextinguisherlocations,andhowtousethemfor smallfiresonly.Knowhowandwhentocall911.Emergencyinformationandaheadcountin/outboardarepostednear thefrontdoor.
4.1AutomobilesonthePropertyDriversmustbelicensedandinsured.Carsmusthavecurrentregistration.Auto repaironthepremisesisnotpermittedwithoutstaffpermission.d, ,
4.1Confidentiality–Z,^>& ,Z, d/
4.1SuccessfulCompletions–AnyhousememberthatsuccessfullycompletesZHousewillreceivetheir $1.00“sobriety”depositbacklessanymoniesneededtomakeanyrepairstoanyitemsorpartsofthehousesoiled, damagedorbrokenbythehousememberand/oranyguestsofthehousemember.Iftheamountnecessarytocleanor repairthedamageditemsorareaexceedsthe“sobriety”depositthenthehousememberwillberesponsibleforthe difference.Successfulcompletionisdefinedascompletingataminimum1)theminimumtimeframeofthehouse(3 months),2)completingtransitionphaserequirements(minimumof1month),and3)participateinhousegraduation ceremony.
BysigningbelowIacknowledgethatIhavereadandunderstandalloftherules,requirementsandpolicieslistedaboveand understandthatNONADHERENCETOTHESERULES/RESPONSIBILITIESCANBECAUSEFORIMMEDIATE/^,Z'.
HouseMembersSignature:__________________________________________
StaffSignature:_________________________________________________