Application for Home Residency

Application for Home Residency for

26 Waitt Ave, Lynn & 356 Vernon St, Wakefield 

 

Contact name and number to schedule a phone interview: Text field

Applicant's Legal Name: Client first name Client middle name Client last name 

Date of Birth: Client birthdate

Age: _Text field__

Phone: (c)Client phone

Email:Client email      Former names: Text fieldText field

Former names:  Text field

Preferred name: Text field

Hometown:Client Address

Most recent address:  Text field

Who referred you to Ruth’s Way?  Text field

What is your current source(s) of income? Text field

How much is your monthly income? Text field

What is your marital status:

Do you have children? If so, what are their names and ages?

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If you are under a physician’s care, please list reason(s), name(s), and contact information.

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Any preexisting medical conditions?  Text field

Allergies:Client allergies

Do you have any physical/emotional/mental limitations? Text field

Please list medications and frequency:  Text field

List the name and contact information of the advocate/social worker/case manager/therapist. Text field 

 

Have you ever had to exchange sex acts for drugs, money, food, or shelter? Yes Checkboxes No Checkboxes N/A Checkboxes

Are you a veteran?  Text field      

Is the Department of Children’s Services involved? 

Checkboxes

If so, what is the name and contact information of the DCF worker?Text field

Do you use alcohol or other drugs? Text field

What is your sobriety date?  Text field

If you have been in treatment for substance use, either inpatient or outpatient, within the last two years, give the name of each program (i.e., detox, treatment center, halfway house), the dates you attended, and the reason for leaving.

TreatmentCenterHistory

Drug of use or misuse (Check all that apply and list a specific form of substance)

Client substances of choice

 

Have you been sober/in recovery in the past?Text field

When and for how long?Text field

Why did you return to use? Text field

Are you currently in a mutual aid or recovery program?  Text field

How many meetings do you attend per week?  Text field

Recovery plan (Be specific):

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Any concerns about harassment or domestic violence? Text field

Any restraining orders?  Text field

Names(s) of people involved?

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Is there anyone who you do not want on the property or to be in contact with? Text field

Do you have any open court cases? If so, where?  Text field

Are you on Probation/Parole? 

Checkboxes

Probation/Parole officer(s) name and contact information  Text field

Are you in Recovery Court?Text field

Where? Text field

What other information would be helpful for us to know about you to serve you best?

Paragraph

List names and telephone numbers of two individuals who may be contacted in the event of an emergency:

Name:Text field Phone:Text field Relationship:Text field

Name:Text field Phone:Text field Relationship:Text field

 

Any member may be asked to leave Ruth's Way for Women for the following reasons:

1.  Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medication(s), or drug(s).

2.  Misusing prescribed or over-the-counter medication(s).

3.  Changing medication(s), dose amount, starting, or stopping medication(s) without notifying Ruth’s Way leadership prior

     to change.

4.  Allowing a person on the property who presents as being under the influence of drugs or alcohol.

5.  In non-compliance with the house standards, policies, or procedures.

6.  In noncompliance with our drug and alcohol policy.

7.  In default of payment of weekly fees.

8.  Has disruptive, disrespectful, or hostile behavior towards Ruth’s Way leadership.

9.  Is verbally or physically abusive towards another house member or Ruth’s Way leadership.

10. Bullying or intimidation of house members or Ruth’s Way leadership.

11. Causes damage or destruction of property.

12. Has lost focus of your recovery plan.

13. Involved in illegal activity or charged with a crime during membership at Ruth’s Way.

14. Stealing from another house member (this includes food).

I have read the above ATTENTION notice and understand that I am applying for residency at Ruth’s Way for Women as a resident of a recovery community. I agree to abide by Ruth’s Way for Women’s standards, policies, procedures, and direction from Ruth’s Way leadership, and to comply with the drug/alcohol policy of Ruth’s Way. I understand that I am subject to immediate expulsion if any of the preceding occur.

Signature:

Signature

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 Ruth’s Way for Women leadership to speak with any professional of the probation/parole department at any time for any reason.

Signature:

Signature

I give my authorization to Ruth’s Way for Women leadership to speak with any employee or representative of the Department of Children and Families at any time for any reason.

Signature:

Signature

I give my consent to Ruth’s Way for Women to use my picture on social media and website.

Signature:

Signature

Work/Volunteer Policy

As a resident of Ruth’s Way for Women, I agree to either work, attend school, attend classes, volunteer, or any other productive activity that is approved by Ruth’s Way leadership. Volunteering instead of work is only an option for someone who is unable to work.

Signature:

Signature

Personal Property Policy

All personal property will be kept neatly in the resident’s room. Residents are not allowed to take or borrow any property of another resident without the other resident’s consent, which includes food.  Ruth’s Way for Women leadership is allowed to inspect any personal property. When I leave Ruth’s Way, I agree to take all of my property with me.  When 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 Ruth’s Way leadership.

Signature:

Signature

Prohibited/Hazardous Items

No weapons, explosives, drug/alcohol paraphernalia are allowed on the property. 

Signature

Medication Policy

The resident is responsible for notifying and providing documentation of any medication to Ruth’s Way for Women leadership. This includes all prescribed and over-the-counter medications.  Medications are to be taken only as prescribed.  Ruth’s Way leadership has the right to count medications that are held by the resident at any time.  Not taking medication as prescribed or misusing medication may require immediate dismissal. If a resident has, uses, shares, buys, or sells alcohol, unauthorized medications, misuses prescribed medications, or any substance that causes a woman to appear intoxicated or under the influence, the resident may be required to leave Ruth’s Way property immediately. Some medications are to be held by Ruth’s Way leadership or a nursing company and made available to the house resident. Medication should always be secured.

Not disclosing any changes of medication(s), dose mount, stopping, or starting medication(s) without notifying Ruth’s Way leadership may require immediate dismissal.  It is the resident’s responsibility to ensure that medications will not cause a false positive. When leaving Ruth’s Way, I agree to take all medications with me or make arrangements to pick up at a later date. Any medication may be disposed of after 48 hours of the resident exiting Ruth’s Way unless arrangements have been made with Ruth’s Way leadership. 

Signature:

Signature

Alcohol/Drug Testing Policy

To ensure the safety of the house, residents are to comply with a minimum of two weekly scheduled and/or random drug/alcohol testing, including breathalyzing. Compliance with random drug/alcohol tests is to be provided within 45 minutes of request. If a suitable urine sample cannot be produced, it will be considered a positive result. Requests to be breathalyzed will be complied with immediately. If a drug/alcohol analysis test is missed, it is considered a positive test and may require immediate dismissal without incident.  Test results will be recorded in either electronic or paper files.

Signature:

Signature

Vehicle Waiver

I understand that I may request or be offered transportation from time to time from a resident, leadership, board of directors member, volunteers, or the managing Resident of Ruth’s Way for Women. I hereby indemnify Ruth’s Way Inc, house resident, leadership, board of director member, volunteers, and/or managing resident of Ruth’s Way for Women from all damage or injury caused to me or others when I willingly accept transportation to or from any location or event, whether Ruth’s Way for Women is related or not.

Signature:

Signature

Dress Code

I agree to be fully dressed when in common areas between 7am and 9pm. Between 9pm and 7am, I agree to be appropriately dressed. Signature:

Signature

By signing below I certify that the information contained in this application is true, that I have read, understand, and accept the conditions set forth above for members and that I agree to abide by said conditions and all house standards, policies, and procedures should I become a member of Ruth’s Way for Women.

Signature:

Signature

 

House Standards

Resident agrees to:

Fees are to be paid on time.


Two scheduled and/or random drug/alcohol urine analysis tests/screens per week.

Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medications, drugs, or misusing prescribed or over-the-counter medications may require immediate dismissal.

If a resident is taking an over-the-counter drug, vitamin, energy drink, etc., it is the Resident’s responsibility to ensure that it will not cause false positive results.

Any and all changes of prescription and non-prescription medication(s) will require that Ruth’s Way’s leadership is notified prior to taking possession of the medication.

Smoking/vaping in designated areas only.

Mutual aid or support meeting requirements if in recovery from substances:  Not working full time, a meeting every day; attending a PHP, a minimum of four meetings per week; working full time, a minimum of three meetings per week.

Comply with all mental health and wellness agreements.

Attend all mandatory in-house meetings.

The kitchen is to be cleaned, dishes washed with soap, dried, and put away immediately after each use.

Resident not allowed in another Resident’s room.

Clean up after herself, make her bed, keep her room clean and neat, and complete chores daily.

Failure to maintain good hygiene and/or a clean living environment may ultimately result in dismissal.

No halogen lamps, candles, or incense.

To be in the house at curfew.

Food is only allowed in the kitchen.  Food is not allowed in living room or bedrooms.

When I move out of Ruth’s Way for Women, 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, direction from leadership, policies, and procedures.

Signature:

Signature

Date  

 

 

Financial Agreement for

Lynn & Wakefield 

 All payments, either paper or electronic, are to be paid to Ruth’s Way Inc.

Move-In Costs

Unless other arrangements have been approved by leadership, a non-refundable payment is required at move-in. This payment includes:

  • First week’s fee
  • Last week’s fee
  • $200 move-in fee

Weekly Payments

  • Weekly fees range from $225 to $300, depending on bed location.
  • Weekly fees are due every Friday by 5:00 PM.
  • Residents who receive income on a monthly or bi-weekly basis must prepay their weekly fees through their next income date.
  • If applicable:  Weekly Air Conditioning fee: $10
  • If applicable:  Weekly excessive utility fee:  $15

Failure to make consistent, scheduled payments may result in dismissal.

Refund Policy

  • A two-week notice is required when moving out.
  • If proper notice is given, the last week’s fee will be applied to the final week.
  • If notice is not given, the last week’s fee is non-refundable.

If a resident leaves early: Any unused full week prepaid fees (excluding the last week’s fee) will be refunded within 10 days after all personal belongings have been removed.

Financial Responsibility

Residents are financially responsible for:

  • Any unpaid weekly fees
  • Property damage
  • Costs incurred by or owed to Ruth’s Way


Agreement

By signing this Financial Agreement, I acknowledge that:

  • I must follow all Rules and Regulations to remain eligible for residency.
  • Residents will be notified of all third-party payers
  • Payments must be made on time as scheduled.
  • Failure to make payments may result in dismissal.
  • I am responsible for all charges incurred from my move-in date through my move-out date.
  • I understand and agree to the refund policy.
  • All charges are due and payable according to this Financial Agreement.

Operator’s Electronic Signature:  Nicole OBrien

Resident Signature:

Signature

Date:Date