Application for House Membership

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?

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How much is your monthly income? Text field

What is your marital status:Client 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?

Paragraph

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

Are you suffering from substance use disorder? 

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 Choice (Check all that apply and list specific form of substance)

Client substances of choice

For substance selected above, please enter below the specific form of that substance use:

Paragraph

 

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):

Paragraph

Any harassment or domestic violence, concerns?Text field

Any restraining orders?

Checkboxes

Names(s) of people involved?

Paragraph

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 informationText 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 prior authorization from Ruth’s Way leadership.

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 weekly membership fees.

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

9. Is verbally or physically abusive towards another 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.

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, 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 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 provide documentation for any medication for approval by Ruth’s Way for Women leadership. This includes all prescribed and non prescribed medications. Medications are not to be in the possession of, shared with or sold to any house member. 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 drug the member may be required to leave Ruth’s Way property immediately. Some medications are to be held by Ruth’s Way leadership. Changing medication(s), dose mount, or starting medication(s) without prior authorization from 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. Any medication may be disposed of after 48 hour 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 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

1. Weekly fees due every Friday.

2. Two drug/alcohol urine analysis tests per week and random testing when requested. Breathalyzed randomly.

3. 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.

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.

5. Any and all prescription and non-prescription medication(s) will require approval from Ruth’s Way’s leadership.

6. Smoking/vaping in designated areas only.

7. If suffering from addiction, a member is to attend a minimum of three meetings (AA/NA, Smart Recovery, etc.) per week. If a member is not working full time, a member is to attend a meeting every day. Multiple meetings in one day will be considered one meeting.

8. Member agrees to comply with all mental health and wellness agreements.

9. Member is to attend all mandatory in-house meetings.

10. Kitchen is to be cleaned, dishes washed and put away immediately after each use.

11. Member is not allowed in another member’s room.

12. Member is responsible for her guest’s behavior. Guests are only allowed in common areas unless permission from leadership is given. Men or significant others are not allowed in the house unless a member has received permission from the staff.

13. Every member is to clean up after herself, make bed, keep her room clean, and neat; and to complete chores daily.

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

15. No halogen lamps, candles, or incense.

16. Curfew Sunday through Thursday is 11pm, Friday and Saturday midnight.

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

On the date that I become a member of Ruth’s Way for Women, fees of $510 for a two person room or $600 for a single person room is required unless arrangements have been made with Ruth’s Way for Women’s leadership. This amount includes the first week and last two weeks of weekly fees. The weekly fee is $170 for a double room or $200 for a single room. Weekly rent is due on Fridays.

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 member receives their next income payment.

Refund Policy

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

Resident Signature:

Signature

Date:Date