SOBER SOLUTIONS TRANSITIONAL HOUSING SERVICES PROGRAM HOUSING SERVICE AGREEMENT

Transcription

1 SOBER SOLUTIONS TRANSITIONAL HOUSING SERVICES PROGRAM HOUSING SERVICE AGREEMENT CLIENT INFORMATION IN-TAKE FORM: Name:. Entry Date: / /20 Unit Address: Room # DOB: Age: Gender: Male, Female Emergency Contact: Phone# Service Fee Monthly Rate $ Processing Fee $ Prorated: Y : N : Prorated Move-in Fee $ Period Beginning: / /20 : Period Ending: / /20 Are you employed? Length of Employment: Name of Employer: Employers Address: City: State: Zip: Phone# ( ) - Other Funding Source: ADASTA : DLU/X : SSI : UNEMP Voucher : Housing Voucher Agency Name: Case Manager Name: Number: ( ) - Have you been in Chemical dependency treatment? Y : N : Program Name: Are you in IOP: Y : N : OP Y : N :

2 Program Name: Case Manager Name: Number: ( ) - Date of last alcohol/drug usage: / /20 Drugs/Substance of choice: Do you have any Physical/Mental health condition? Y: N: Please explain: Are you receiving treatment? Y: N: Program Name: Doctor Name: Number: ( ) - Do you take prescription drugs? if so list Names & Dosage: Are you on probation: Y : N : DOC# DOC Reporting Office: CCO Name: Phone # ( ) - Criminal History: Conviction #1: Conviction #2: Conviction #3: Conviction #4:

3 SOBER SOLUTIONS TRANSITIONAL HOUSING SERVICES PROGRAM Consent for Services Agreement I hereby authorize staff and volunteers at Sober Solutions Transitional Residential Recovery Housing Services Program to provide residential recovery and reentry related transitional services in accordance with my individual service plan. Services will include a structured and supportive temporary living community conducive to chemical dependency recovery and reentry policies at designated residential property, (urine/breath analysis testing at random and/or for just cause). I understand that this transitional services program has a usual length of 6-12 month of stay. I also understand that if I refuse to follow my plan and the rules set forth in this agreement which is to stay clean and sober, fully engaged in my designed program, as well as reporting to all care givers and co-operate with the random and for just cause urine analysis screening. If found to be in violation of any rule in this agreement I will receive a Corrective Memo and given 24hrs to curb and cure the situation, if I refuse I can/will be discharged from this housing program and given 72hrs to remove my property from the premises in according to this agreement for failure to comply. I hereby acknowledge that I have received, read, reviewed and understand the rules. I agree to abide by these rules and acknowledge that Sober Solutions Transitional Residential Recovery Housing Services Program may amend them at any time in order to maintain a safe and productive environment for recovery. I understand that Sober Solutions Transitional Residential Recovery Housing Services Program is not responsible for any loss, theft or damage to my personal property during my stay. I further understand that Sober Solutions Transitional Housing Services Program is not responsible for any injury, harm or incapacity resulting from my condition, or any action on my part in conformance with all the rules. I agree to behave in a manner that does not inflict harm on me or to others during my stay. I agree to hold all parties harmless. SERVICE FEE S I agree to pay a one-time $150 non-refundable processing fee when moving in, and a monthly service fee due on the 1st or before the 3th day of the month. Payments must be made by Money Order. The combined service fees for house funds are also due on the 1st or before the 3th day of each month. The house fee covers basic hygienic supplies, toilet paper and cleaning supplies. I also agree to pay a $50.00 penalty if the monthly service fee is paid after the 3rd of each month. I agree to secure either a voucher or rental assistance on or before the 1st of each month if necessary, and be able to show proof thereof, and a promissory note MUST be signed.

4 Failure to provide proof of funds will result in a penalty of $50.00, and dismissal after the 5th. I acknowledge that this service fee may be increased any time and that I will be given a 30 day written notice. I acknowledge that there are no refunds of any fees, for any reason- no exceptions. I also acknowledge that Sober Solutions Transitional Residential Recovery Housing Services Program pursue collection of all money s owed for unpaid services and for any damage done by me to Sober Solutions Transitional Residential Recovery Housing Services Program property. NO-TOLERANCY POLICY: The following violations will be subject to terminations: Please initial each of the following 1. Violating this agreement by using any drugs or alcohol regardless of where this has occurred. This includes falsifying illnesses to obtain Prescription Narcotic s(drug Seeking Behavior), will be grounds for termination 2. Declining to cooperate with a drug test. 3. Possession of any weapons, engaging in any illegal activities and/or associating with other persons who are engaged in illegal activities is a violating of the policy s set forth in this agreement. 4. Engaging in threats, name calling, harassment, any verbal or physical abuse or threats thereof directed at any one involved with Sober Solutions Transitional Residential Recovery Housing Services Program. 5. If I fail to pay any of the monthly service fees on time, or failing to provide proof that I have made arrangements for financial assistance by the 3rd of each month. 6. The first 14 days, I must adhere to a 9:00 pm curfew. Regular curfew is 10pm (Sunday Thursday) 12pm (Friday and Saturday). After my 14 day orientation period, I may spend the nights out (All DOC clients must provide written proof from CCO s) with prior permission from manager. I will sign out and leave a contact number where I can be reached by the Manager. If I signout for longer than 24hrs, I will check in daily. If I am ascent for three (3dy) consecutive days without permission, the terms of my housing agreement will be considered abandon and this agreement will terminated. Violation of the curfew period will result in a UA at the resident expense. 7. If this agreement is violated for any of the reasons listed above, I agree to vacate the program within 72 hours of written notice if I failure to cure the cited violated behavior within 24hrs. I understand that clients terminated for stated reason(s) will not be allowed on the property for any reason after vacating. A client that is required to vacate the property may apply to re-enter after completing treatment, or for visiting after 30 days.

5 8. I acknowledge that any personal belongings will be disposed of promptly after my departure upon termination unless I make arrangement with the resident manager to return my property. Sober Solutions Transitional Housing Services Program is NOT responsible for my personal belongings. PROGRAM, GENERAL AND VISITOR RULES: 1. CLEANLINESS AND SANITATION: I acknowledge that I am required to bath regularly, and I will wash and change the bedding weekly. I am required to keep my living and common areas neat and clean at all times. I am also responsible for keeping the stove, fridge, walls and sink clean. Odor affects my neighbors, and garbage is a fire hazard that attracts insects and is unsafe. No trash or garbage or any obstruction is allowed in the stairwells or hallways. 2. UNIT AND ROOM INSPECTION: There will be daily inspection of all living units and rooms at 10am. All living unit and rooms will be presentable at time of inspection (Exception for those who employment require sleep during inspection hours). Failure to adhere to the cleanliness policy will result in a corrective action. 3. MAINTAINING A POSITIVE ATTITUDE TOWARDS EVERYONE: All residences are requiring treating each other in a manner that promotes dignity common courtesy, decency and respect. Maintaining a positive attitude towards toward other residents and member of the community regardless of what your recovery throw at you on your path only assist you in building character. 4. HARASSMENT; Harassment on the basis of race, creed, color, national origin, age, sex, marital status, sexual orientation, and/or mental/physical disability is not permitted. 5. VIOLENCE; Physical Violence, Threats of bodily harm to another resident and possession of weapons are prohibited and will result in IMMEDIATE termination. 6. STAY CLEAN AND SOBER: any use of alcohol, or drugs are grounds for IMMEDIATE termination and any paraphernalia is strictly prohibited. This is a ZERO TOLERANCE ENVOIRNMENT, and this policy is strictly enforced and if not, It is grounds for immediate termination 7. BREATH AND URINE TESTING: Random and for cause testing are routine. I am required to co-operate and failure to do so will be grounds for IMMEDIATE termination. 8. PRESCRIPTION MEDICATION 1: I will report to the Resident Manager if I am taking prescription medication. I understand this will be kept in confidence. I will not withdraw from any prescribed medication without supervision of a Medical Doctor.

6 9. PRESCRIPTION MEDICATION 2: I understand that any medication containing alcohol and/or narcotics is prohibited, unless it is prescribed by a license physician and/or professional medical practitioner. Such medications will be secured in a locking containment (Lock Box and/or Safe) at resident expense to prevent unauthorized access in furtherance of the program s fundamental goal of clean and sober living. Residents are responsible for their medication and shall not share prescription medication with other residents. Residents who engage in the unauthorized accessing or sharing of prescription medicines will be immediately terminated from the program for unlawful distribution of prescribed pharmaceutical medication. 10. SECURITY: I will not enter my unit by any way other than the Front/Back doors. I will not give my keys to anyone (especially visitor or nonresident. If I lose my key I will report the lost key and the $20.00 cost of replacement will be at my expense. I will return any/all keys when I leave the program. I will not make copies of any keys given by Sober Solutions Transitional Residential Recovery Housing Services Program. I will surrender them IMMEDIATELY upon request. I must maintain communication with the Resident Manager. If I am out of contact for more than 48 hours, I am considered terminated from the program. I will stay in the room assigned by the Resident Manager and I will not move without approval. 11. SMOKING: "NO" SMOKING IN UNITS. Smoking is only allowed in designated areas. I will dispose of my cigarette butts only in ashtrays or cans. 12. ANIMALS: No Animals are allowed. 13. PROGRAM /HOUSE MEETINGS ARE MANDATORY. Program meetings will be held once a week (to be determining by location). A $20.00 fine will be issued for non-attendance. Exceptions are made for work, with prior written approval from the Program Managers. Problems may be addressed at house meetings or brought to the attention of the Program Manager as they develop. 14. RESPONSIBILITY: I am responsible for turning off lights, TV, computer and/or any electrical appliance that is not being used. Failure to do so will result in a $10.00 fine. This is a GROUP EFFORT at cost control. 15. CHORES: I will complete daily chores as assigned by Resident Manager or Chore Monitor. I understand that if I fail to do my chore, I will be fined $5.00, and I still have to complete the chore. 16. ACTIONS: Three (3) write-ups for any reason will and can be cause for removal.

7 17. STORAGE: Sober Solutions Transitional Residential Recovery Housing Services Program is a shared living residential recovery environment. Cabinet and Freezer space are limited so you are only allowed to purchase $25.00 (Dry Goods) and $25.00 (Freezer Goods) per week. 18. Closet and Dresser Drawer space is also limited. Clothing and other personal items Cannot exceed the space assigned. Anyone with items that exceed their assigned space will be given an opportunity to downsize property or donate excess items to a charity of their chosen. 19. All food items/personal belongings must be marked with the name of the owner and be taken with you when moving out, regardless if the move out is voluntary or involuntary. Sober Solutions Transitional Residential Recovery Housing Services Program is not responsible for any items left behind. 20. Vehicles: Sober Solutions Transitional Residential Recovery Housing Services Program is a shared living residential recovery environment. Residents and Guest are only allowed to park one insured vehicle on Sober Solutions property. Residents and guest are also required to have a valid Driver License in order to operate and/or park a vehicle on Property Managed by Sober Solutions. 21. COURTESY: Wearing appropriate attire is required at all times. 22. Noise Levels; maintaining an appropriate noise, is a levels not audible outside of the unit and/or your room is required. Sound travels and many clients work different hours and is sleeping at different times. Being respectful of everyone right to a peaceful living environment is appreciated and strongly encourage. 23. MOVING OUT: Sober Solutions Transitional Residential Recovery Housing Services Program requests a 20 day written notice preceding the end of the month when I plan to move. 24. REPAIRS AND MAINTENCE: I will report anything damaged and/or broken items to the Manager for repair, in particular water and/or electrical problem. I acknowledge that I am responsible for paying for any property damage that I cause. 25. GUESTS: All residents will be respectful to one another Guess. No overnight guests are allowed. No guests under the age of 18yrs are allowed in living unit without being accompanied by an adult (Exception is made for biological relatives Children and proof of relationship must be submitted prior to visiting). I am responsible for my guest and their behavior. Guests are only allowed only in common area and are not allowed to operated unit equipment and/or prepare meals. All guests must Sign-in and leave by 11pm and will remain in the presence of the resident for whom they are visiting

8 26. SEXUAL CONTACT: is not allowed on the premises and / or between residents. 27. LOANING MONEY AND THEFT: I will not loan any money to any other client. I will not take anything without asking. Borrowing items without permission (sugar, milk etc.) is theft. 12 STEP RECOVERY INVOLVEMENTS: Having a sponsor, support team and a relapse prevention plan is essential to one s recovery. I acknowledge that I will prepare a relapse prevention plan, attend three (3) Sober Support group meetings per week and I will be required to show proof of my attendance at these meetings at the weekly house meetings. I have read all items and I agree to the terms in this service agreement, I understand that Sober Solutions Transitional Housing Services operates under RCW Drug and Alcohol Free Housing and Program of Recovery. The nature of this RCW provide termination of this agreement within 72hrs of a written notice to any resident who is found to be using drugs or alcohol and who refuses curb their behavior and cure the situation by obtaining professional assistance to deal with the problem with-in 24hrs of the citation. It also provide termination of this agreement within 72hrs of a written notice to any resident who is found to be breaking any Local, State and/or Federal Laws. I understand that D.O.C and other Housing Voucher Agencies will be notified if I am terminated for cause, if applicable. I give my permission for Manager to communicate with any and all agencies that I am involved with such as Churches, DOC, DOP, Treatment Counselors, Sponsors, Payee Services and/or Case Managers. Client Signature Date Program Management / Assignees Date

9 Sober Solutions Transitional Housing Services Program CLIENTS QUESTIONARIE 1. Name: 2. Clean Date: 3. Drug/s of Choice: 4. Are you actively involved in a 12-Step program? Y N If yes do you have a Home Group: 5. Do you have a Sponsor? Sponsor Name: 6. How many meetings do you attend a week? 7. How do you feel? 8. How do you feel about your life right now? 9. Identify Problem area/issues in your life

10 10. How have you addressed these issues? Do you need help with addressing or solving these issues? 12. What changes have/are you making (to your lifestyle) toward achieving a Quality life? 13. Where do you see yourself in 6 months? 14. Will you need help in developing a strategy? 15. Are you willing and committed to the life changing strategy that you created? Signature Date