Application for House Membership
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
Home town:Client Address
Who referred you to Ruth’s Way?
Client Referred By
What is your current source(s) of income? Text field
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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?
Client health problems
Allergies:Client allergies
Do you have any physical/emotional/mental limitations? Text field
Are you taking any medications?
Checkboxes
Please list medications and frequency:
Medication
Do you have an advocate/social worker/case manager/therapist? Checkboxes
If so, list their name and contact information.
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Are you a veteran?
Checkboxes
Are you eligible for veterans benefits?
Checkboxes
Have you been in contact with Veterans Affairs?
Checkboxes
Are you in contact with a Veterans Service Officer? If so, Where? 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?
Checkboxes
Are you recovering from:
Checkboxes
Sobriety Date RecoveryHistory
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 (Check all that apply and list specific form of substance)
Client substances of choice
For the substance selected above, please enter below the specific form of that substance use:
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Have you been sober/in recovery in the past?
Checkboxes
When and for how long?Text field
Why did you return to use? Text field
What is your perception of recovery?Text field
Recovery goals (BeSpecific):
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Any harassment or domestic violence, concerns?Text field
Any restraining orders?
Checkboxes
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
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 to be under the influence of drugs or alcohol.
5. In non-compliance with the house standards, policies, or procedures.
6. In noncompliance with drug and alcohol policy.
7. In default of payment of membership 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:
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 allow Ruth’s Way for Women to use my picture on social media and website.
Signature:
Signature
Work/Volunteer Policy
As a member 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 member’s room. Members are not allowed to borrow any property of another member without the other member’s consent, this includes food. Ruth’s Way for Women leadership is allowed to inspect any and all personal property, this 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 member is responsible to notify and provide 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 house member at any time. Not taking medication as prescribed or misusing medication may require immediate dismissal. If a member 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 member may be required to leave Ruth’s Way property immediately. Some medications are to be held by Ruth’s Way leadership or nursing company and made available to the house member.
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 member’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 them up at a later date. Any medication may be disposed of after 48 hours of members exiting Ruth’s Way unless arrangements have been made with Ruth’s Way leadership.
Signature:
Signature
Alcohol/Drug Testing Policy
Members are to comply with scheduled two weekly drug/alcohol analysis testing as well as random tests, including breathalyzing. Compliance with random drug/alcohol analysis tests are to be provided within 45 minutes of request. If an immediately suitable urine sample cannot be produced, a member is to be in the presence of Ruth’s Way leadership until a suitable sample is provided. Requests to be breathalyzed will be complied with immediately. If drug/alcohol analysis test is missed, it is considered a positive test and may require immediate dismissal without incident.
Signature:
Signature
Vehicle Waiver
I understand that I may request or be offered transportation from time to time from a house member, leadership, member of the board of directors, volunteers, or managing members of Ruth’s Way for Women. I hereby indemnify Ruth’s Way Inc., house members, leadership, board of director members, volunteers, and/or managing members 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.
Two drug/alcohol urine analysis tests/screens and/or breathalyzed two times per week, as well as random testing/breathalyzing when requested.
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 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.
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 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. Multiple meetings in one day will be considered one meeting.
Member agrees to comply with all mental health and wellness agreements.
Member 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.
Member is not allowed in another member’s room.
Every member is to clean up after herself, make bed, keep her room clean, and neat; and to 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.
Member 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:
Date
Financial Agreement
Non-refundable payment of three weeks of fees is due upon intake (includes the first week’s fee, start-up fee, and the last week's fees), unless arrangements have been made with Ruth’s Way for Women’s leadership.
The weekly fee ranges between $200 and $325 depending on the location and the room. Key replacement fee is $20.
If a member receives income on a monthly or bi-weekly basis, the member agrees to prepay weekly fees up to the date that the member receives their next income payment.
Refund Policy
Two weeks' notice is required when moving out of Ruth's Way for Women. If notice is provided, the last week's fee will be applied towards the last week. If notice is not provided the last week's fee will not be refunded.
The member is responsible for any other money owed. The member 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 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 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