Daily Living Recovery House Application
Name:Client first nameClient last name Preferred Name:Client nickname
Date of Birth:Client birthdate Email:Client email
Please leave phone number for follow up: Client phone
What is your current source(s) of income? Text field
Are you taking medications? Checkboxes
Please list medications and frequency: Medication
Do you have a recovery coach/social worker/case manager/therapist? Therapist/Clinician
If so, list the name and contact information:Text field
Substance Use History
Sobriety Date:RecoveryHistory
Substances of Use (Check all that apply)
Client substances of choice
Have you been sober/clean in the past? Checkboxes When and for how long were you sober/clean? Text field
Why did you return to using? Paragraph
Recovery Goals
What is your recovery pathway:
Checkboxes
Other - Please explain Text field
Do you have a sponsor/mentor? Checkboxes
What does recovery mean to you? Paragraph
Criminal History
Do you have experience with the justice system? Criminal History
Can you share how your past experiences with the justice system have shaped who you are today and the steps you've taken toward positive growth and reintegration into your community? Paragraph
Are you on Probation/Parole? Probation
Parole/Probation(s) officer name and contact information:Text field
Do you have open cases?Checkboxes
Have you ever been convicted of a sex offense? CheckboxesIf yes, please explain Paragraph
Additional Information
What other information would be helpful for us to know about you to support you better? Client notes
List the contact information of people we may contact in the event of an emergency: Text field
Self Identification
Gender:
(Please check one of the options below)
Client gender
Race/Ethnicity:
(Please check one of the descriptions below corresponding to the ethnic group with which you identify.)
Client race
House Standards
1. Weekly fees are due every Friday.
2. Two drug/alcohol urine analysis tests are required per week, along with random testing when requested. Members may also be breathalyzed at random.
3. Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medications, drugs, or misusing prescribed or over-the-counter medications may result in immediate dismissal.
4. If a member is taking an over-the-counter drug, vitamin, energy drink, etc., it is the member’s responsibility to ensure that it will not cause false positive results. All prescription and non-prescription medication(s) require approval from a doctor.
5. Smoking/vaping is permitted only in designated areas.
6. Residents must attend a minimum of three meetings (AA/NA, Smart Recovery, etc.) per week. If a resident is not working full-time, they are required to attend a meeting every day. Multiple meetings in one day will be considered as one meeting.
7. Residents must attend all mandatory in-house meetings.
8. The kitchen must be cleaned, dishes washed, and put away immediately after each use.
9. Residents are not allowed in another resident’s room.
10. Residents are responsible for their guests' behavior. Guests are only allowed in common areas unless permission is given. Women or significant others are not allowed in the house unless the resident has received prior permission from the staff.
11. Every resident is responsible for cleaning up after themselves, making their bed, keeping their room clean and neat, and completing daily chores. Failure to maintain good hygiene and/or a clean living environment may result in dismissal.
12. No halogen lamps, candles, or incense are permitted.
13. Curfew is 11 p.m. Sunday through Thursday, and midnight on Friday and Saturday.
When I move out of Daily Living Recovery House, I will give two weeks' notice and leave a clean space for the next person, i.e. vacuum, etc. I will take all personal property and medications with me when I leave.
I have read and agree to abide by the above-stated standards, directions, policies, and procedures.
Signature
Equity and Inclusion Pledge
Daily Living Recovery House is committed to creating a brave, safe, and diverse environment and is proud to be a welcoming and inclusive sober living home. All qualified applicants will receive consideration for sober living without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
As a DLRH guest, I pledge to the DLRH Equity and Inclusion pledge and if I violate this pledge, I understand I will engage in restorative justice, commit to learning, or be subject to discharge from the home.
Signature
Financial Agreement
On the date that I become a resident of Daily Living Recovery House, fees of $275, or $1,191 per month, with an initial move-in fee of $300. The total move-in cost is $575 for weekly payers or $1,491 for monthly payers. Residents must provide a two-week notice prior to moving out. Residents may be eligible for a refund of the last week's fees if there are no major rule violations within 30 days prior to moving out, no property damage, and no outstanding balance. All DLRH applicants are required to pay a $20 refundable key replacement fee upfront. This fee will be fully refunded upon the return of your key when you transition, complete your program, or move on from DLRH.
Refund Policy
Residents may be eligible for a refund of the last week's fees if there are no major rule violations, property damage, or outstanding balances. Refunds are issued within two weeks of leaving the home.
I understand that failure to make consistent scheduled payments when due may result in my discharge from Daily Living Recovery House. In acceptance of the FINANCIAL AGREEMENT with Daily Living Recovery House, I agree that to qualify for Daily Living Recovery House I must adhere to the attached Rules and Regulations and make my scheduled payments when due. I further understand that failure to make payments when due may result in my dismissal from Daily Living Recovery House. Any unpaid account balance at the time of moving out is subject to the cost of collections and lawyers' fees if required. Residents will be informed of payments from 3rd party payers for any fees paid on their behalf. Residents must take responsibility for their own and other residents' safety and health. Residents must understand that the length of stay at the house is "resident-driven." Al emergency contact information must be collected from residents. I promise to settle all charges with Daily Living Recovery House. All its charges were rendered to me from admission to the day of moving out. I understand the refund policy and I understand that the total of such charges is due and payable according to this FINANCIAL AGREEMENT.
SignatureSignature
ATTENTION: Daily Living Recovery House may require immediate dismissal from the house without prior notice of any resident for the following reasons:
1. Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medication, or drug(s).
2. Misusing prescribed or over-the-counter medications).
3. Changing medications), dose amount, starting, or stopping medications) without prior authorization from a doctor.
5. Allowing a person on the property who presents to be under the influence of drugs or alcohol.
6. In noncompliance with the house standards, policies, or procedures.
7. In noncompliance with drug and alcohol policy.
8. In default of payment of weekly fees.
9. Has disruptive, disrespectful, or hostile behavior towards Daily Living Recovery House.
10. Is verbally or physically abusive towards another resident of Daily Living Recovery House.
11. Bullying or intimidation of house residents or Daily Living Recovery House.
12. Causes damage or destruction of property.
13. Involved in illegal activity.
I have read the above ATTENTION notice and understand that I am applying at, Daily Living Recovery House, as a resident of a recovery community. I agree to abide by Daily Living Recovery House's principles and fully subject myself to Daily Living Recovery House standards, policies, procedures, and direction from Daily Living Recovery House, and comply with the drug/alcohol policy of Daily Living Recovery House. I understand that I am subject to immediate dismissal if any of the preceding occur. If I am on Probation or Parole, I understand that they will be contacted immediately upon my dismissal. By signing below, I am giving my authorization to Daily Living Recovery House to speak with any resident of the probation/parole department at any time for any reason. I allow Daily Living Recovery House to use my picture on social media and websites.
Work/Volunteer Policy
As a resident of Daily Living Recovery House, I agree to either work, attend school, attend classes, volunteer, or do any other productive activity that is approved by Daily Living Recovery House. Volunteering instead of work is only an option for someone unable to work.
Personal Property Policy
All personal property will be kept neatly in the resident's room. Residents are not allowed to borrow any property of another resident without the other resident's consent, this includes food. Daily Living Recovery House is allowed to inspect all personal property, this includes any electronic property. When I leave Daily Living Recovery House agrees to take all my property with me. If I leave for any reason without personal property, it will be held for up to 48 hours. After 48 hours the property will be discarded or donated unless arrangements have been made with Daily Living Recovery House.
Medication Policy
The resident is responsible to provide documentation for any medication to Daily Living Recovery House. This includes all prescribed and non-prescribed medications. Medications are not to be in the possession of, shared with, or sold to any house resident. Medications are to be taken only as prescribed. Daily Living Recovery House has the right to count medications that are held by house residents at any time. Not taking medication as prescribed or misusing medication may require immediate dismissal. If a resident is in possession of, using, sharing, buying, or selling alcohol, unauthorized medications, misusing prescribed medications, or any drug the resident may be required to leave Daily Living Recovery House property immediately. Some medications are to be held by Daily Living Recovery House.
a. Participants must store medications in a lockbox, stored in the manager's office, and a spare key must be given to the house manager. Sharing medications with other residents are not allowed.
When leaving Daily Living Recovery House, I agree to take all medications with me. Any medication may be disposed of after 48 hours of residents exiting Daily Living Recovery House unless arrangements have been made with Daily Living Recovery House.
Returning to Use Policy
We recognize that recovery is a journey, and setbacks may occur. If a relapse happens, residents are encouraged to communicate openly so we can provide support. Temporary adjustments, such as a pause in residency or referrals to additional care, may be necessary to ensure safety and well-being. Reentry will be guided by an individualized recovery plan. Relapse is not failure, and we remain committed to helping residents grow and continue their recovery journey.
Search Policy
To maintain a safe and supportive living environment, staff may conduct searches of personal spaces when there is a reasonable belief of policy violations, such as possession of prohibited items. Residents will be informed prior to a search and given the opportunity to be present. Searches will be conducted respectfully, with minimal intrusion, and only to ensure the safety and well-being of all residents. Our goal is to uphold accountability while fostering trust and dignity.
Signature:Signature