Name:                                           Date of Birth:

 

Address:                                                                                   City, State, Zip:

 

Former Address:

 

Telephone:                                  Cell #:                                  Social Security#:         

 

Marital Status:                            Child Support:                       Health Insurance:                      

 

Psychiatrist:                                                                             Physician:

 

Clinician/Counselor:

 

List medical conditions:                                                                     

 

Are you disabled? (disability?)                                                                     HIV Status:

 

Are you an Alcoholic/Addict?                                       Drug of Choice: #1                    #2                  #3 

 

Have you been to rehab?                  Halfway House?                 If so, where?

 

Date of last drink/drug?                  Do you attend 12Step meetings?            If so, do you have a sponsor?    

 

List Prescription Medications:

 

Source of Income:

 

Employer:                                                                                       Employer Telephone #:

 

Salary:                                                How Long On the Job:                         

 

If unemployed, are you seeking work?    yes  r  no r                     Are you a veteran?     yes  r  no r 

 

Have you been arrested and/or convicted of a sex offense?            Are you required to register as a sex-offender?          

 

Have you been arrested and/or convicted of arson?

 

Do you have open warrants or court cases?        yes  r  no r           Parole/Probation?                         

 

I give Twelve Step permission to speak with my parole officer:       yes  r    no r

 

PO’s Name:                                  

 

PO’s Location:                                                          PO’s Telephone #:

 

In case of emergency, please notify: (relationship)

 

Upon your leaving the Twelve Step Education Program, where should we forward your mail to?                

 

____________________________________________________________________________________________

SIGNATURE OF AGREEMENT – RESIDENT:                                                                                      DATE:

 

SIGNATURE OF TWELVE STEP REPRESENTATIVE:                                                                            DATE:

 

 

 

Procedure for suspected drug/alcohol use:

·          A voluntary urine or blood screen may be requested at the residents’ expense.  

 

·          I understand that if I relapse and seek help/treatment, I may be eligible to return to a Twelve Step location, however,

not necessarily the same location.   Relapse is cause for immediate eviction.

 

ABSOLUTELY NO CASH WILL BE ACCEPTED FOR PROGRAM FEES BY ANY TWELVE STEP EMPLOYEE

NO REFUNDS

 

·          Residents on SSI/SSDI or other monthly incomes MUST pay monthly.

 

·          Two weeks advance fee is required upon program entry for residents paying weekly along with first weeks

Program fee.

 

·          One week advance fee is required upon program entry for residents paying Monthly along with first month’s program fee.  Your Advance fee will only be used toward credit of program fees upon receipt of a two week notice of departure.

 

·          Resident’s who bounce checks will be liable for a $25 bounced check charge fee and will have to pay program

fees with money order or cashier’s check only.

 

ANONYMITY IS VITAL TO THE Twelve-Step Education Program of New England, Inc. AND its Residents.

 

HOUSE RULES AND RESPONSIBILITIES

 

o       no drinking

o        no drugging

o        resident is responsible for prompt payment of program fees

o        attend a minimum of three 12-step meetings per week

o        attend a manadtory weekly house meeting

o        take medication(s) as prescribed – (non-narcotics)

o        clean up after yourself

o        take messages for other house members

o        if you are to be away overnight, you MUST inform the house managers

o        be responsible for daily house chore

o        if it does not belong to you, do not use it or take it

o        stealing, destruction of property, Disruptive, threatening, violent and/or abusive behavior toward Staff or residents will not be tolerated

       this will be cause for immediate eviction

o        absouletely no sexual contact between residents

       this will be cause for immediate eviction

o        no destrction of twelve step property or any other resident’s property

       this will be cause for immediate eviction

o        use or possesion of alcohol or illegal substances in or on twelve step properties will be grounds

for being banned permanently from all locations

o        upon eviction, former twelve step education program resident will not enter any twelve step

education program location presmises

o        house manager have the right to enter the resident’s room without prior notice

o        smoking in designated area(s) only

o        Twelve Step is not responsible for personal belongings during residency or when left behind. 

upon leaving twelve step any personal belongings left behind must be picked up within 14 days or

  items will be donated to a local charity.  prior arrangements must be made with the house manager

  prior to picking up items

 

ÆNON-ADHERENCE TO THESE RULES AND RESPONSIBILITIES IS CAUSE FOR IMMEDIATE EVICTION

ÆI waive any landlord-tenant rights I might have with respect to residency.

ÆI have read the above and understand and I fully subject myself to the rules/responsibilities of the house.

 

 

SIGNATURE OF AGREEMENT – RESIDENT:                                                                                      DATE: