APPLICATION FOR RESIDENCY KILLINGSWORTH 1831 PENDLETON ST * COLUMBIA SC * * * FAX

Transcription

1 APPLICATION FOR RESIDENCY KILLINGSWORTH 1831 PENDLETON ST * COLUMBIA SC * * * FAX application for residency 1 Date 1. Name last first middle/maiden Also known by (list other names used) Most recent address Previous address Current Phone numbers and 2. Date of Birth Age Social Security # Religious preference Race Marital status: Single Married Divorced Separated Other Children? Names, genders, and complete birthdates; use back of this page if necessary: 3. Have you had a complete medical exam in the last year? Yes No If yes, physician s name Location List any present medication(s),,

2 application for residency 2 Your present state of health 4. Are you employed? If no, why not? Employer s name & type of business Your job title/description List other jobs you have held 5. Education (please check the ones that apply to you) High school graduate GED completed Last grade completed Some college College graduate Where? Currently in school Course of study 6. Who referred you to Killingsworth? agency or group Contact person 7. Emergency, contact Name relationship address city state zip home phone work phone other phone

3 application for residency 3 8. Have you ever been treated for alcohol/drug addiction? Yes No If you have any history of drug use, what did you use? Your last treatment when where List other times and places that you have received addiction treatment or counseling: 9. Have you ever been counseled or hospitalized for emotional/psychiatric problems? If yes, for what diagnosis Your last treatment when where 10. Have you ever been on probation? If yes, list offense, when, and where 11. Have you ever been imprisoned? If yes, where? Offense Time served 12. Are you currently on probation or parole? Yes No Length of time Officer/Agent contact name phone 13. What is your source of financial support while living at Killingsworth? Self Other Vocational Rehabilitation Counselor s name

4 application for residency List the goals you will work on while living at Killingworth: a. b. c. I,, agree that the above information is complete and true to printed name the best of my knowledge, and that I promise, if accepted into Killingsworth, I will abide by the Killingworth rules and policies. applicant s signature date signed staff notes: Accepted Admission date Declined Reason (s) Interviewer s signature

5 ACKNOWLEDGEMENT OF KILLINGSWORTH PROGRAM REQUIREMENTS AND CONSENT TO THE PAYMENT OF FEES I,, acknowledge by my signature below that the Killingsworth program has been explained to me, and that I have received my personal copy of the rules and written guidelines. I have also had any questions about the Killingsworth program answered to my satisfaction. If accepted, I further agree to pay all fees required for my stay here, and I will pay these fees on time and in accordance with Killingsworth policy. I understand that the fees include a $25 nonrefundable rent deposit when I move in, and a weekly charge of $ for rent, which is $15.00 per night. I understand that I am required to have a source of regular, reliable income to fund my room and board fees. I understand I am responsible for payment for any prescription medicines I am issued by a doctor/health provide and also for services provided by such. Resident's signature Witness for Killingsworth Date

6 RELEASE OF INFORMATION I,, hereby authorize the employees of Killingsworth to exchange and release any or all of the contents of information in my file or about conversations with me to medical providers, including pharmacies, and educational facilities, social agencies, counselors, mental health agencies, or prospective employers for the purpose of assisting in all phases of programming and planning. This consent will remain in effect until my departure from Killingsworth. I also authorize medical providers, including pharmacies, and educational facilities, social agencies, counselors, mental health agencies, or prospective employers to release and/ or exchange contents of my case files and conversations to Killingsworth. Resident's signature Witness for Killingsworth Date

7 Killingsworth Drug Testing Policy It is our highest priority to assure a safe and peaceful environment for all the residents of Killingsworth. Therefore, it is the policy of Killingsworth to test randomly for drug and alcohol use. This policy applies to every resident, not just to those who have been referred from alcohol and drug treatment facilities. When you are asked for a urine specimen for drug testing the following collection procedures will apply, with NO exceptions. 1. You will not be allowed to leave the office once you have been asked for a specimen. If you need water, coffee, etc. we will bring it to you. You will not be allowed contact with any other resident until the specimen has been obtained. 2. You will not be allowed to run any water in the staff bathroom (flushing toilet, washing hands etc.) until the specimen has been handed to the staff person. 3. A staff member will stand in the bathroom or in the doorway of the bathroom during collection.this allows us to prove the validity of the specimen should it become necessary. 4. You will be asked to initial a form verifying that it is your specimen and that it has not been altered. If you refuse to cooperate, or if you are unable to provide a specimen within a reasonable amount of time (around one hour) we will assume that you are unwilling. Failure to submit a specimen or tampering with a specimen in any way may result in immediate termination. If the screen is found positive you may be asked to move immediately. Specimens that test positive are repeated for confirmation, and kept on file for at least one year. I have read and understand the drug testing policy. signature date

8 EMERGENCY INFORMATION The following information is requested of each resident along with a photograph taken upon admission to Killingsworth. It's sole purpose is emergency use for your safety and protection. Name Any alias Date of birth Social Security Number Height Color of hair Weight Color of eyes Driver's License Number (include state) Auto year, make and model Tag # Friend or relative in Columbia (or living closest to Columbia): 1. Name Telephone # Address 2. Name Telephone # Address Attach photos here (one face, and one full body) This will be completed by Killingsworth Staff.

9 AGREEMENT TO MAINTAIN ENVIRONMENT I,, understand that living in a cooperative household such as Killingsworth requires that I help maintain and when required improve the living area. The living area includes the house and grounds. Maintenance is keeping my bedroom area clean, neat and uncluttered; and completing any assigned task referred to as a detail. My signature is my agreement to do this. I understand that I will be assigned a regular detail. I understand it is my responsibility to notify staff when I have completed my detail or any other assigned task. It is my responsibility to notify staff if and why I am unable to perform maintenance details or keep my bedroom area in order. I understand if I ignore my assigned detail or leave it incomplete, I will be issued a W which means warning, and my curfew will be curtailed to 9 p.m. I understand that repeated inattention to my detail is interpreted as disinterest in living in this cooperative residence called Killingsworth. resident signature date staff signature as witness date Pendleton Street Columbia, SC office fax

10 AGREEMENT TO REMOVE PERSONAL BELONGINGS I,, understand that when I am discharged* from Killingsworth or decide to move from Killingsworth I must remove my belongings. I understand that if my belongings are left on the Killingsworth premises for over a week (seven days) after I leave that on the eighth day they will be considered abandoned and will be discarded. *discharged also may refer to begin AWOL (away with out offical leave) for over 24 hours without contacting fulltime staff. resident signature date staff signature as witness date Pendleton Street Columbia, SC office fax

11 Promissory Note To: Reverend Diane A Moseley, Executive Director Killingsworth Home From: Date: Subject: Promise to Pay Killingsworth Funds owed Rent Deposit Damage I promise to pay Killingsworth all monies owed for deposit, room and board (rent) and any other charges incurred. I understand my account must be cleared within 90 days of my leaving or discharge. I owe Killingsworth $. Reason for indebtedness: I plan to pay in this manner: I understand that I must pay these monies in order to be in good standing. I understand that my credit history will be reported to the Credit Bureau(s) when my account is in arrears over 90 days. I also understand that legal action will be taken if I fail to repay this debt. If Killingsworth agrees to arrange a payment plan with me and I fail to make a payment as agreed for 90 days, my account will be placed with a Magistrate s Office for legal action. This promissory note is a valid contract and by my signature I confirm that I understand this procedure. Resident Witness, Staff

12 KILLINGSWORTH HOUSE POLICIES Revised January 2014 All House Policies and Interpretation of the House Rules are decided by the staff together. We agree on what they mean, and support each other in interpreting issues not specifically addressed in these policies. 1. Rent includes room and board, and is paid in advance. A deposit and one week's rent is due when you move in. After that, rent is paid at least one week ahead. You should receive a receipt for each payment; if not, please notify the director. All residents are expected to pay rent on time. Rent is due every Wednesday unless otherwise approved by the full-time staff. Rent may be paid with cash, debit card or a paycheck. * Residents who work for tips pay daily out of their tips to keep a zero balance. If you do not pay your rent, there are consequences. The first 30 days you are a resident, you may carry a balance as you seek work and rent support. After 30 days of being a resident, if you owe more than one week's rent you are on restriction. After 90 days of being a resident, you are expected to have and keep a zero rent balance. If you owe any rent at all after 90 days, you are on restriction, and may be asked to move. Rent restriction means: 1. You are restricted to the house for any free time you have. 2. Other than work, you may go to AA or NA meetings, doctor's appointments, church services and counseling sessions. You have two hours for each meeting. 3. You must turn in your pay stub and discuss payment with staff until your rent debt is cleared. No exceptions. 2. All residents are required to work or be in an approved training, educational or rehabilitation program a minimum of 30 hours a week within two weeks after moving in. Policy for those unemployed or not in school 1. When you move into Killingsworth if you do not already have 30 hrs. of productive activity scheduled every week, the priority is to find those 30 hours. Most residents work. However, if you can keep your rent paid you may go to school or do volunteer work. 2. Until you have 30 hrs weekly, you must discuss your plans with the staff every day Monday through Friday. The time can be arranged depending on your schedule, but your daily plans must be discussed. This requirement is for those who are unemployed, and also for those with part-time work less than 30 hours a week. 3. Use the hours between 9:00 am and 4:00 PM every week day to look for work. You may go to 12-Step meetings, but only at midday. Do not watch television until AFTER 4:00 PM. 4. Fill out and turn in employment/job search sheets every day. 5. Two weeks after moving in to Killingsworth, if you are still unemployed, your effort and motivation will be evaluated. 1

13 Standards for Working 1. If you are new in recovery you may not regularly work more than 40 hours a week. Discuss any requested exceptions with full-time staff. 2. Unacceptable work situations: bars; liquor stores; "adult" entertainment or any work for independent contractors who pay in cash. 3. Once you have a 30-hour program, do NOT change it or quit before discussing with staff. If you have difficulties at work or school discuss the problems with the staff. 4. Expect the staff to confirm your employment. 5. Absence from ajob or program for any reason requires that the staff be notified. If you are sick and cannot work, you cannot go anywhere else -- except to see a doctor. 6. Your work schedule must allow you to be at Killingsworth to attend the Monday night House Meeting every week. 3. Your rent includes 3 meals a day. The kitchen is open for breakfast and lunch. Food is available for you to fix your own breakfast and lunch, and clean up afterwards. After eating, the kitchen will be cleaned by each one who uses it. This means food is properly stored; dirty dishes rinsed out and put in the dishwasher; pots and pans are washed, dried, and put away; and nothing is left in the sink. Supper is served between 6:00 and 7:30 PM Monday through Thursday. The buffet is left out until 7:30 PM. Unless you are at work, in school or drug court, you are expected for supper every evening Monday through Thursday. Discuss any exceptions with the staff. Unless you have askedfor a saved plate, there will be no meals eaten after the buffet is put up. The kitchen is locked overnight. Saved Plates Tuesday through Thursday plates may be saved for those with commitments during suppertime. A plate is prepared for you if you sign up for it on the sign-out board. Your food must be eaten within 24 hours. If you request a saved plate and do not eat it, you risk losing this option. Weekend Meals Our cook prepares meals for weekend suppers. Food will be available from 6:00 PM - 9:00 PM. Those who do eat supper on the weekend are responsible to clean up afterwards. Personal Food Any food in your room must be kept in secure containers. Any food garbage MUST be taken downstairs and disposed of. Killingsworth is not responsible for your personal food. Expect staff to check rooms for open containers of food, and remove it if it is found. 4. All residents help take care of the house. *Bedrooms: Your room must be clean when you leave the house. Rooms are checked daily. Room searches may be conducted by the staff at any time. DO NOT PUT ANYTHING ON THE WALLS, DOORS, OR WOODWORK. DO NOT MOVE FURNITURE IN THE ROOMS OR BETWEEN THE ROOMS. 2

14 *Details: Assigned household duties are required to be done as described on the detail sheet, and they are checked daily. Details are to be maintained all day. However, they must be completed no later than 10:00 PM. during the week and by 12 midnight on Fridays and Saturdays When you complete your detail, it is your responsibility to have it checked. Expect the staff to check your detail personally. They will let you know if it needs redoing. When you are going to be away, you are responsible for getting someone to do your detail. Choose wisely; if they fail to do it, the consequence is yours. *Clean-up Weekends: On Clean-up Weekend there are no overnights on Friday. Once a month residents do major household cleanup. On cleanup weekend, your chores should be done with extra care and more thoroughly than usual. Your room and detail assignment is checked in your presence. assignment is complete and approved, remain in the house. Until your Clean-up Weekend PERSONAL CLEANLINESS All residents are required to shower or bathe daily, wash their hair at least weekly and launder their clothing and linens regularly. Between 9 AM and 9 PM do not come downstairs unless dressed in street clothes. At no time do residents go outside unless dressed in street clothing. Exception: fire or fire drills! Lying down is done on your bed, not on the downstairs couches. If you are sleepy, go to bed. 5. Curfew is 10:00 PM, Sunday through Thursday, and 12:00 midnight on Friday and Saturday. You are expected to honor the curfew and return to the house on time. Emergencies are the only acceptable excuses for arriving late. Call and notify the staff if at all possible. For the first 30 days you live at Killingsworth the curfew is 9:00 PM every night. Work Curfew: Residents whose jobs require them to work late hours must return to Killingsworth no later than 12:30 am. These schedules must be known to the staff before residents come in at this late hour. Discuss your schedule with staff if you have questions. 6. Residents are responsible for the security of their belongings. Killingsworth is not responsible for your money or other valuables. There is a resident lock box in the office if you want to turn in anything for safekeeping. * Killingsworth strongly discourages borrowing or lending of personal possessions or money. * Killingsworth strongly discourages residents giving each other rides in personal cars unless the owner of the car is not inconvenienced. Whenever rides are shared, it is expected that the car's owner will be reimbursed for gas. 3

15 DONATIONS MAY NOT BE TOUCHED UNTIL YOU ARE INVITED TO LOOK AND SEE WHAT YOU CAN USE. NEW RESIDENTS ARE GIVEN FIRST CHOICE. Residents may not store furniture, appliances, or other items on Killingsworth property. Limited storage space does not allow residents to accumulate a large amount of clothing or other personal items. Keep only seasonal clothing in your room. Belongings may be neatly placed in boxes under your bed. No clutter. When moving out it is your responsibility to pack your things. If someone else has to pack for you, Killingsworth is not responsible if something is missing. You have one week to come pick up your belongs before they are disposed of. 7. Residents notify staff when leaving and returning to the house. Residents may not leave Killingsworth after 9:00 PM. Visitors may not come after 9:00 PM We need to know at all times how many people are in the house and who they are. Sign out and sign in on the available board when you leave and when you return. If possible, also speak to the staff and let them know you are leaving. Residents may not let each other into the house. Residents may not unlock doors or leave doors unlocked. Only in special circumstances when asked by a staff member may a resident admit someone into the house. 8. Use good manners when talking on any phone:.! No screaming! No profanity! CELL PHONES: * Do not talk on your cell phone in any room where there are other people. Find a private place to talk. It is your responsibility to leave the room, not everyone else!. * Do not talk on your cell phone while doing your detail. * You may not keep your cell phone in your bedroom overnight....not even on the weekends * Turn in your cell phone by 11 PM during the week, and midnight on Fridays and Saturdays. Staff will collect outstanding phones between 2:00 AM and 3:00 AM. STAFF PHONE: * The staff phone is for emergency use only. Exceptions are made for calls with therapists, or with a family in crisis. 9. All medication is turned in to staff and taken as prescribed. Vitamins, birth control and asthma medication are exceptions to this rule. Communicate changes your doctor makes in your medication to the staff. Killingsworth is not in the practice of giving out medication. We want to encourage responsible use of medication, both prescribed and over the counter. We record medication as distributed. Failure to take medicine as prescribed may be grounds for termination. Drug samples require written instructions from a doctor for use. When you plan to be away more than 24 hours from Killingsworth, medications are given to you to take along. You are expected to take it as prescribed while you are away. 4

16 10. Residents are not allowed any use of alcohol or drugs. This rule applies to all residents -- to those in recovery AND also to those who are not. Any use or relapse results in termination. Residents are also monitored for "using behaviors." For those with an addiction history -- During your first 90 days at Killingsworth you must make 90 meetings. NO EXCUSES. Monday and Thursday night in-house meetings may be counted, but only for the first 90 days. After 90 days residency, those in recovery are expected to make at least 4 meetings a week. You must document your attendance at meetings. Discussion with staff will help determine which l2-step program is appropriate for you. Attendance means you show up on time and stay until after the closing prayer. You must have a sponsor who is active in recovery soon after moving in. We want to know their names and that you are talking to them. Have your sponsor sign your meeting sheet weekly and turn it in each Monday by 4:00 PM. If we fmd out that you are seeing someone who is using, dealing, or who has abused you in the past, you may be asked to leave. It's just not safe. 11. Residents treat other residents and staffwith respect in language and conduct. Respectful language means: no profanity; no obscenity; no threatening words; no gossip. Language is not an addiction. You can control the way you speak. The way you talk downstairs and upstairs should be the same. Respectful conduct means: no fighting; no stealing; no obscene gestures; and no sexual acting out -- either with guests or with other residents. This can be explained more plainly if you don't understand. See the Executive Director. 12. Unless staff is present, offices are off-limits. Knock before entering. We insist. After knocking, wait for an invitation to come in. Unless it is a true emergency, do not interrupt discussions or telephone conversation. If the staff person has to leave the office while you are there, you leave also, and wait in the hall until she returns. 13. Smoking is permitted only on the outside porches. You may smoke on the "swing side" of the front porch. The "mailbox side" of the porch is nonsmoking. If you smoke, keep ash cans and trays clean, regardless of whose detail it is. No smoking between the hours of 12:30 AM and 6:00 AM at Killingsworth anywhere. No smoking upstairs ever! No candles may be lit upstairs; the risk of fire is the same as with cigarettes. 5

17 14. Visitors to Killingsworth and visiting with each other: Guests: Visitors may come between 9:00 AM and 9:00 PM. After 9:00 PM all visitors are asked to leave. Guests remain in the front of the house to protect the privacy of other residents. Because there is limited visiting space, guests may visit up to two hours. Your guests are expected to behave appropriately. Children who visit must always be accompanied by an adult. Visiting with other residents: Because respecting privacy is important at Killingsworth residents must visit with each other downstairs. Do not go into anyone's room other than your own -- not to talk, not to borrow anything, not to "hang out. "Visiting in other resident's rooms may be grounds for termination. 15. Roommates who wish to sleep have priority. Quiet upstairs at all times. Loud music and noise will not be tolerated. Because residents work various shifts and sleep at different hours, there should be quiet at all times, especially in the halls. Do not raise your voice in the hall. Be careful about stomping your feet. Snooze alarm clocks are discouraged at Killingsworth. Those who wish to sleep always have priority. Roommates who remain in the room while someone sleeps may not turn on a radio unless played with headphones. Anytime music or conversation --can be heard in the hall, it is too loud. If your roommate is in bed, do not turn on the overhead light! 16. Residents attend all house meetings unless working or in class. Mondays and Thursdays are "in-house" nights. Meetings are held Monday and Thursday after supper, and attendance is required. Monday night is mandatory. In-house evenings are intended for personal reflection and community time. You are expected in time for supper. Do not expect the staffto come find you for in-house meetings. You do not have to actively participate if you do not want to, but you may not sleep through them nor disrupt them. 17. Overnights You may request an overnight pass when ** you do not have to go to work or school before 3:00 PM the following day, and ** have a $0 rent balance for at least three weeks in a row, and ** have at least a 30-hour a week program, and ** have successfully completed your work details in the house all week. (means No W's) 6

18 A maximum of 4 overnights per month will be approved. Pass requests must be turned in Qy Wednesday and are approved by full time staff only. See staff for approval for weekday passes. Unemployed residents and residents who have lived at Killingsworth less than 30 days do not have overnight privileges except in special circumstances. RECAP: To have overnight privileges, the following must apply-- I. 30 hours or more of work, school, or other approved "program" 2. $0 rent balance for at least three consecutive weeks 3. not on restriction 4. you are not scheduled for work or school until 3:00 PM or later the next day 5. you have successfully completed your work details all week 6. you have filled out a request form for a pass in a timely manner. If a resident is gone for 24 hours without notifying the staff, she is terminated. 18. Physical Health People living at Killingsworth are expected to be in generally good health. All residents are encouraged to get a physical exam or provide information about an exam in the last six months. If you have a condition that needs medical care, including pregnancy, you must consult a doctor regularly, and keep your appointments. If a doctor makes a referral or suggests any medical treatment you are expected to follow those recommendations. Failure to follow medical recommendations can mean termination. ~~ If you go to the hospital while living at Killingsworth, it is your financial responsibility. We cannot provide medical care. Any convalescence or disability that prevents you from working your 30 hours+ program for longer than 5 days cannot be accommodated, and you will have to make other living arrangements. 19. Mental Health If you have an aftercare plan that calls for therapy, you are expected to arrange counseling as soon as possible and keep all appointments. If you are in therapy you will be asked to sign a release which will allow the staff of Killingsworth and your therapist to talk -- not about the details of your life, but -- about how we might support your work in counseling or otherwise be helpful to you. 20. Use of Vehicles If you bring a vehicle to Killingsworth we need a copy of your driver's license and to see your current registration and proof of insurance. If a vehicle is used illegally or irresponsibly, the keys may be held for a time as a resident learns proper use of her time and resources. Residents may not park in the parking lot beside the house. responsible for getting a parking permit for the street. If you have a car, you are 7

19 21. Do not bring in the mail. Getting the mail from the mailbox is the staffs responsibility. Ask the staff for your mail. 22. Use of the laundry facilities. A coin-operated washer and dryer are available; we do not furnish change so get your own. Plan to do laundry when you can stay in the house until your clothes are clean and dry and back in your room. If you leave the house while your clothes are washing or drying, do not expect to find them when you return. Ask the staff about them. 23. The television and DVDNCR are shared equipment. When channel surfing, the majority rules. If you rather talk than watch the program, go to another room. Any DVD brought into the house will be subject to screening by the staff -- no crazy or X-rated material. Personal DVD players are used with head phones. No exceptions. Televisions are not allowed in bedrooms. 24. If rules are broken, you are on house restriction. Restriction means you are housebound; stay at home; no free time. You go to work, and one recovery meeting a day (2 hours maximum for a meeting only). Any exceptions for therapy, church services, or personal business must be cleared with the staff. Additional expectations may be added to a restriction to address specific behaviors. 25. Security of the house. Our commitment is to provide a safe place for you to live. * You must sign in and sign out to let us know when you are in the house. * We keep all the doors locked all the time. * Only staff members open the doors. Do not open the door for one another. * Pull the locked door shut behind yourself when you leave the house We realize this may be a brief inconvenience when you may have to wait for a staff member who is on the phone or otherwise occupied. But this is a small price to pay for a safe, secure place to live. The door must remain locked even when you go out to smoke. Caution: How you dress and behave on the porch, in the yard, and in the community affects our reputation and ultimately the security of the house. 26. Use of Social Media Because the use of information technology and social media has become so widely used more quickly than people have learned to use it wisely, this rule was put into place. 8

20 Any resident having a Facebook page is expected to "friend" the staff of Killingsworth; and any resident who has a Twitter account is expected to allow Killingsworth staff to "follow" them. Because discipline in the wise use of social media is critical to the health and safety of our household, anyone refusing to comply will be asked to find another place to live Violation of any House Rule will result in consequences appropriate to the rule broken. The House Rules are subject to revision at any time by staff agreement. 9