Medication Policy Agreement 

Acceptable and properly prescribed medication, like MAT prescriptions are permitted on the premise of Empowering Potential Housing.  Empowering Potential Housing is not a medical facility and in accordance with the State of California regulations will not administer any medication to residents.  All residents are responsible for the proper storage and self- administration of their own medication(s).

While residents will be responsible for self-administration, they agree to the below stipulations to remain in compliance with Empowering Potential Housing’s medication policy. By initialing each stipulation and signing at the bottom of the agreement the Resident is acknowledging that they have read and understood the medication policy and agree to comply with all the terms to remain at Empowering Potential Housing: 

Initial Below:

Initials Text fieldPlease note – we do NOT accept in the home any Opiates, Adderall and Benzodiazepines.  Additionally, Methadone and Soboxone is allowed in take-home form on a case-by-case basis please speak to House Leader/Senior resident or Operator.  Mostly you must be dosed at your medical facility by a nurse or healthcare worker.

Initials Text fieldAll prescription and non-prescription medications are to be in their original containers as obtained from the pharmacy or over the counter.

Initials Text fieldDates of the medication are to be current, and prescription is not to be expired.

Initials Text fieldAll medications are to be accurately and correctly listed on intake form.

Initials Text fieldMedication(s) are to be taken only as prescribed.

Initials Text fieldResidents are responsible for the proper storage of their medication and must demonstrate that medications are kept in an appropriately locked container stored away from any visible surfaces.

Initials Text fieldResidents are provided with a LOANED lock box from Empowering Potential Housing.  The box must be returned when you leave the home.  If you do not receive a lock box at intake, please ask for one ASAP!

Initials Text fieldMedication should always locked away - excluding when it is time for self-administration.  You must immediately return medication to locked container following self-administration.

Initials Text fieldResident agrees to notify Empowering Potential Housing of any new or refilled prescriptions within 48 hours in order to maintain accuracy of your file.

Initials Text fieldMedication is not to be shared or misused/abused in any way.

Initials Text fieldAll medications are subject to random search and Resident agrees to comply with any necessary searches (i.e providing access to container, etc.).

By signing below I, Client first name Client last name(print your name) acknowledge that I have read and agree with the aforementioned terms of the Empowering Potential Housing medication policy. And I understand that any violation of the above terms is cause for removal from the property.

Resident Signature: Signature

Date: Date