One Step

Application for Home Residency

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

Applicants 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

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

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 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 harassment or domestic violence, concerns? 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?

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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

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 membership at, Ruth’s Way for Women, as a member of a sober community. I agree to abide by Ruth’s Way for Women’s principles and fully subject myself to Ruth’s Way’s standards, policies, procedures, and direction from Ruth’s Way leadership, and 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 discharge. By signing below, I am giving my authorization to Ruth’s Way for Women leadership to speak with any member of the probation/parole department at any time for any reason.

Signature:

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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:

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I allow Ruth’s Way for Women to use my picture on social media and the 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 in lieu 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 and all personal property, which includes any electronic property. When I leave Ruth’s Way, I agree to take all of 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 Ruth’s Way leadership.

Signature:

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 is in possession of, using, sharing, buying, or selling alcohol, unauthorized medications, misusing 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 the nursing company and made available to the house resident. A resident is to sign a release of information for every prescriber.

Not disclosing any changes of medication(s), dose mount, 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

Residents are to comply with scheduled and random drug/alcohol testing, including breathalyzing. Compliance with random drug/alcohol analysis tests are 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.

Signature:

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Vehicle Waiver

I understand that I may request or be offered transportation from time to time from a resident, leadership, member of the board of directors, 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

Fees are to be paid on time. Multiple scheduled and/or random drug/alcohol urine analysis tests/screens.

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.

Resident agrees to comply with all mental health and wellness agreements.

Resident is to 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 is not allowed in another Resident’s room.

Every resident is to 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.

Resident is required 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

A non-refundable entrance fee payment of $640 for Lynn and $750 for Wakefield is due upon intake unless arrangements have been made with Ruth’s Way for Women’s leadership.

If the entrance fee is paid, the weekly fee ($225 - $325, depending on the bed location) is due on the second week. Key replacement fee is $25.

If a resident receives an income on a monthly or bi-weekly basis, the resident agrees to prepay weekly fees up to the date that the resident receives their next income payment.

Two weeks' notice is required when moving out of Ruth's Way for Women. If notice is provided, the last week's fees will be applied towards the last week. If notice is not provided, the last week's fee will not be refunded.

Refund Policy

If a resident leaves prematurely, any unused prepaid weeks, excluding the last week’s fees, will be reimbursed within 14 days from the date that all personal property is removed from Ruth’s Way’s property.

The resident is responsible for any other money owed. The resident is financially responsible for any property damage, weekly fees, or costs incurred to or by Ruth's Way for Women. I understand that failure to make consistent scheduled payments when due may result in my discharge from Ruth’s Way for Women.

In acceptance of the FINANCIAL AGREEMENT with Ruth’s Way for Women, I agree that to qualify for Ruth’s Way for Women, I must adhere to the attached standards, policies, and procedures and make my scheduled payments when due. I further understand that failure to make payments when due may result in my dismissal from Ruth’s Way for Women. 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.” I promise to settle all charges with Ruth’s Way for Women. All its charges 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 are due and payable according to this FINANCIAL AGREEMENT.

Operator's Electronic Signature: Nicole OBrien

Resident Signature:

Signature

Date:Date