Name: Client first nameClient last name
Date of birth: Client birthdate
Email: Resident email
Phone: Resident phone
Current address: Resident mailing address
Marital Status: Text field
Projected Move Out Date: Resident move out date
Number of Children: Text field
Currently Paying Child Support? If Yes How Much? Text field
Move In Date: Resident move in date
Referred By: Resident referred by
Recovery Attempts: Text field
Fellowship: Text field
Sponsor: Text field
HomeGroup: Text field
Drug Choice: Resident substance of choice
Time of Use: Text field
Last Date of Use: Resident sobriety date
Sex Or Arson Crime: Text field
Last Grade Completed: Text field
Name of School: Resident current school
Graduated: Text field
Occupation: Resident occupation
Current Work Status: Text field
Employer:Resident current employment
Employer Phone:Text field
Employer Address:Text field
Length: Text field
Primary Care Doctor: Text field
How long?Text field
Address: Text field
Phone: Text field
Suicide Attempts: Text field
City: Text field
State: Text field
Therapist: Text field
Allergies: Resident allergies
Medical Conditions: Resident diagnosis
Name: Text field
I authorize the verification of the information provided on this form as to my personal information and employment. This is for application to Michael’s House.
Signature of applicant: Signature
Date: Text field
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Income Verification Application
Date: Date Name:Client first name Client last name
Address:Client Address Client City Client State Client Zip
Are you currently employed? Text field
Employer: Text field Weekly income:Text field
How do you get paid: Text field (weekly/Monthly)
Do you receive unemployment? Text field
Amount: Text field
How long will continue to receive Unemployment:Text field
Do you receive disability? Text field Amount:_Text field
Do you receive Social Security or SSI? Text field What benefits:Text fieldAmount:Text field
Do you have any other income? Text field
What kind of income: ex. retirement, annuity, pension… income:Text fieldAmount:Text field
Do you currently have any available cash (for initial payment)? Text field Amount:Text field
Do you have the $150 initial payment to move in? (payment must be received before move in date and will be applied to first weeks rent)
Do you have any Family / Friends that are willing to help pay for your treatment? Text field
If so what is the relationship: Text fieldAmount:Text field
Michael's House is owned and operated by the Michael J. Dias Foundation. The Michael J. Dias Foundation is a 501C (3) charitable organization and donations are tax deductible to the extent allowed by law.
Michael J. Dias Foundation
The mission of our Foundation is to aid and educate individuals and families on substance abuse and help those that are battling the disease of addiction.
Sober Living Environment Overview
It is our belief that recovery is possible for ANYONE, if they are ready.
Our House is home that offers a structured, safe, clean drug free environment and a positive setting to engage in life outside of a treatment setting. We are spiritually based and use the 12 principles of recovery as a foundation for living. We offer a family experience, where individuals can rely on each other in both good times and bad.
Residents are required to actively and aggressively pursue recovery and will be guided through the process by incorporating a diverse group of peer mentors. This will take place in a group and in an individual setting.
A structured schedule allows for educational groups, individualized mentoring, personal reflection, and life-skill building tasks.
Throughout your stay at Our House random drug and breathalyzer tests will be administered regularly with no prior notice.
COST: The current Fees fee schedule is $600.00 per month or $150.00 per week, to be paid in advance.
A fee of $150 will be collected before move in date and will be applied to residents first week upon arrival date.
In recovery responsibility and accountability play a significant role for each individual and the community. We believe that each Resident should be accountable for their actions and that of their housemates. Each member of the community is expected to engage in the structure and activities the house provides.
Our House is equipped with a 24-hour surveillance system and a keyless entry system individualized for each Resident.
Our House is a Sober Community for alcohol or drug addicted men seeking recovery, 18 years or older. Everyone must pass a thirteen-panel drug test as part of the admission process (tests are administered at check-in).
We are a non-medical and non-clinical home, so as a result, we are private pay only. Insurance is not accepted. Weekly fees are discussed after initial review.
Potential Residents will be subject to a phone interview, and a face-to-face interview to be accepted to Our House. Residents will be notified of admission status within 24 hours of their interview.
The following will result in immediate discharge from Our House:
· Zero Tolerance Policy on Alcohol/Drug Use
· Positive drug or alcohol screen
· Refusal to take a Drug or alcohol screen
· Acts of Violence to self or others
· Stealing or destruction of property
· Any Criminal Activity
· Failure to pay weekly fees for more than 2 weeks
· You are arrested for any new offenses
· Any inappropriate contact with another Residents or visitor
· Any Paraphernalia, unauthorized prescription medications or weapons
Disrespecting Director, Staff, or Board Member
The Residents of Our House are expected to conduct themselves and their behavior as individuals being productive members of a community and society. The house is guided by the principles of the twelve-steps. We believe that people make mistakes and will utilize a three-strike policy for correction of behaviors that go against our guiding principles. The Director has a full list of correctible offense that include, but are not limited to:
· Engaging questionable moral behaviors- lying, Cheating, Strip Clubs, Massage parlors and Solicitation of sex.
· Missed or late curfew
· Failure to complete any responsibilities: Chores, Room Cleanliness, Hygiene
· Missing Weekly House Meeting
· Glamorizing past use
Date: Text field
Michael J. Dias Houses Philosophy:
1. Orientation Phase (1-3 Months): Restriction, Curfew and Length of this phase determined by length of Sobriety, Recovery efforts and employment.
• Generally, the first stage of their stay is dedicated to utilizing the 12-principles, Orientation.
• Attend AA/NA Meetings 4 times weekly.
• House meetings are held every Monday night/Wednesday Nights, attendance is MANDATORY.
• Must seek gainful employment within first 30 days. If Resident is not employed at end of 30 days, volunteer work is required.
• Resident to meet with Director for at least one-hour weekly.
• No passes are allowed during this Phase (first 3 months).
2. Preparation Phase (2-6 Months): Passes, Curfew and Length of this phase determined by length of Sobriety, Recovery efforts and employment.
• Must have an outside Sponsor and meet with them regularly before overnight passes will be granted.
• Must meet with the Director for at least one-hour weekly.
• House meetings are held every Monday/Wednesday Nights; attendance is MANDATORY.
• Continue to work a Recovery with an outside Sponsor.
• Must be employed.
• Pass schedule for Phase 2: 4 - 24-hour pass per month to be utilized on weekends ONLY IF ALL ASSIGNED CHORES ARE COMPLETED AND ROOM IS CLEAN.
3. Maintenance Phase (5-9 Months): Passes, Curfew and Length of this phase determined by length of Sobriety, Recovery efforts and employment.
• Must actively continue to work a recovery with an outside Sponsor.
• Attend 12 Step Meetings 4 times Weekly.
• House meetings are held every Monday night; attendance is MANDATORY.
• Mentor incoming Residents working in earlier phases.
• Must be employed.
• Pass schedule for Phase 3: 8 - 24-hour pass per month to be utilized on the weekends ONLY IF ALL ASSIGNED CHORES ARE COMPLETED AND ROOM IS CLEAN.
4. Transitional Phase (9-18 Months): Passes, Curfew and Length of this phase determined by length of Sobriety, Recovery efforts and employment.
• Must actively continue to work the 12 Steps of Recovery with an outside Sponsor.
• Attend Recovery Meetings 4 times Weekly.
• Must meet with Director Bi-Weekly for one hour.
• House meetings are held every Monday/Wednesday nights; attendance is MANDATORY.
• Must be actively seeking Transitional Housing.
DURING ALL PHASES OF YOUR STAY Residents must adhere to
ALL requirements outlined in our Philosophy and ALL Policies of the House.
1. Safety – Our House is under 24-hour camera monitoring, for resident’s safety. Residents are also required to use the Sober Housing App developed by One-Step for communication and Monitoring. Length of Sobriety and Stay at Our House will determine the appropriate level of monitoring.
2. Sponsor/ Mentor/ Therapist - By Phase 2, ALL Residents are required to obtain an outside Sponsor/ Mentor/ Therapist (neither the Director nor a House Captain can serve as a Sponsor to a resident while at Our House).
3. Regarding Passes
a) All passes MUST BE SUBMITTED, electronically or writing/hand delivered in person to the House Director, no later than Thursday at 6:00 p.m.
b) Passes will only be granted if all Phase requirements are met to the Director’s satisfaction.
c) Be aware that when passes are taken, upon your return, you have two hours to notify the Staff that you are back in the House and a drug and/or breathalyzer test will be taken.
4. House Cleanliness - Trash cans MUST BE EMPTIED DAILY and FLOORS MUST BE SWEPT DAILY and WASHED SEVERAL TIMES PER WEEK.
5. Full House and/or chore inspection – This inspection will be conducted by the Director every Friday between 9:00 – 3:00 p.m. Individual passes will be withheld if the inspection is deemed inadequate. Once the problem is corrected, the pass will be released.
a) Rooms shall always be neat and clean, and all beds must be made daily.
b) All personal belongings must be stored in appropriate /assigned locations and not scattered throughout your room (example: laundry in laundry bin, clothes in dressers, toiletries in caddy, shoes under bed, etc.).
6. Surveillance Cameras - Be aware that for all activities at Our House are monitored and recorded by video surveillance cameras.
Resident’s Signature: Signature Date: Text field
Print Name Legibly:Text field
Contact Info: The person seeking recovery would contact (413) 788-0270 or (413) 769-3028
Moving toward a drug free communityThe Michael J. Dias Foundation is a 501c (3) charitable organization and donations are fully tax deductible to the extent allowed by law. Tax ID#: 45-4675913
Website: mdiasfoundation.org Email: email@example.com
Telephone Foundation: 413-391-2997 Our House: 413-788-0270
398 East Street Ludlow Ma 01056
“Moving toward a drug-free community”