Client Application

Thank you for choosing Rocky Mountain Sober Living

*The information provided in this document is strictly confidential and will not be shared/sold or used for any reason other than that of Rocky Mountain Sober Living LLC’s program and emergency purposes.

 

 

Client Information:

Client Name:Client first nameClient middle nameClient last name

Pronouns:Client pronoun  Nickname:Client nickname
Date of Birth:Client birthdate Social Security #SSN
Cell #Client phone
Valid Drivers License or State ID #:Text field

Social Security Card: Dropdown
Email: Client email
Personal Address:Client Address

Client CityClient StateClient Zip
Sobriety BirthDate:Date

 



CRIMINAL HISTORY:

Do you have any felonies?: Dropdown
If YES, please list the charges:

 Text field


Have you ever been charged with a sex crime? Dropdown

Are you currently on Parole or Probation? Dropdown

Probation/Case Worker Name:Text field

County/CityText field

Phone NumberText field

Email:Text field



MEDICAL INSURANCE:

Insurances

 

 

EMPLOYMENT: 

EmploymentHistory

 

 

 

Vehicle Data:

Vehicle Make/Model:Text field
License Plate:Text field
Auto Insurance:Text field
Auto Ins Co:Text field
Insurance Policy #:Text field
Insurance Expiration Date:Text field


*All Vehicles must have insurance and current registration if you are found non-compliant, you will be subject to further action, including but not limited to program probation, non-compliance restriction, and program discharge.
I acknowledge all information above is truthful and accurate: Initials Text field

 

EMERGENCY CONTACT:

Contact

 I hereby allow RMSL to contact my Emergency Contact as a reference Initials Text field

 

Please list your substances of choice:

Client substances of choice

 

 

MEDICATIONS:

*Please Note: All current medications must be listed below. If there are any changes to medications in the duration of your participation in Rocky Mountain Sober Living LLC’s Program, these changes must be approved by staff, and a new “Medication Update Form” must be filled out.

 

Prescribed Medications (If none, type n/a): Text field

 

 



WHAT WE OFFER:

Rocky Mountain Sober Living LLC provides Recovery Residences and Coaching Services where individuals can continue working on living skills, developing relationships in the recovery community, and maintaining their sobriety while reintegrating into the workforce and community. Clients are held to high standards promoting growth, accountability, and personal development in their recovery. 
What you are responsible for: 

Clients are responsible for providing their own food, hygiene products, Laundry Detergent, clothing, and any personal items they may wish to decorate the rooms with (Must Be Approved By RMSL). Rocky Mountain Sober Living LLC will provide all bedding, pillows, cleaning products, and common household items. 


Initials: Initials Text field

Admission Guidelines: 

• Minimum 18yrs of age 

• Must be sober and able to provide a clean UA/BA upon admission 

• Able to fulfill financial obligations 

• Be able/willing to work, attend school, or volunteer full-time (or any combination thereof) 

• Willing to participate in a 12-step or Recovery program 

• Willing to participate in Rocky Mountain Sober Living LLC’s Program

Initials: Initials Text field

 

Program Fees:

Intake Fee: $150 
Monthly Fees: $700
Weekly Fee: $175.00
Daily Prorated Fee: $25.00
Overnight UA Cup: $5.00
*All Fees are Non-Refundable.
*Prices may be subject to change at any time. Clients will be notified of any changes. 
Upon move-in, a non-refundable $150.00 intake fee is due along with any other applicable program fees. Prorated fees may be applied at the discretion of RMSL Staff. If a client is discharged by Rocky Mountain Sober Living LLC or discharged on their own accord at any point, any fees paid will be forfeited. Program fees will NOT be prorated for the exiting week in which a client is discharged from the program. 


Program Fees will be collected monthly on the 1st Sunday of each month or on the corresponding day of admission each month. If financial obligations are not met, the client will be considered non-compliant with Rocky Mountain Sober Living LLC’s program and will be subject to further action including but not limited to program probation, non-compliance restriction, and program discharge. 


Late fees will be applied if the account becomes delinquent. There will be a fee of $25 beginning the day after clients' fees are due. If the account exceeds one week of delinquency, there will be an additional $50 per week applied to the client's account. Program fees shall not exceed a maximum of 1-week delinquent for any reason. 


Bed reservations may be made in advance prior to the client moving in. A fee of $150.00 (intake fee) must be paid to secure a bed. This reservation fee is good for a period of NOT more than 7 days. This is a non-refundable fee. 


I acknowledge all fees paid are final, and no refunds will be given.:Initials Text field


*NOTE* Should fees not be paid on time, and the account becomes delinquent, immediate restrictions will be imposed. 


Restrictions may be up to and include but are not limited to the following: 


Early curfew, visitor/guest limitations, program probation, and/or program discharge. 

Initials: Initials Text field

Zero-Tolerance: 

Rocky Mountain Sober Living LLC has a strict policy regarding the use of drugs and/or alcohol (this includes marijuana or any form of THC Based CBD products, as well as Kratom). Any use of these substances and/or contraband/paraphernalia found on premises will result in immediate action up to and including, but not limited to, non-compliance restriction and/or immediate discharge. Clients with knowledge of other clients using the program that fails to inform staff will be subject to the same/similar action. 


Physical or verbal abuse, acts or threats of violence, and hostile behaviors WILL NOT be tolerated. Immediate action will be taken up to and including but not limited to: behavioral contracts, immediate discharge, and/or contacting law enforcement. 

 Initials: Initials Text field

 

Sobriety Monitoring: 

Clients are subject to mandatory random urinalysis and breathalyzer screening. Testing will be done at the staff/house manager’s discretion at a minimum of, but not limited to 2 BA’s and 1 UA per week. If the client is suspected of using or acting suspiciously and any testing is performed beyond the required, there will be additional fees assessed at the client’s expense. The client will be given 30 mins from the time of being asked to produce urinalysis. Upon being asked for a breathalyzer, the client will be expected to submit it immediately. “False Positive” test results will NOT be accepted. Should the client fail to meet these guidelines or refuse any test, immediate action will be taken, up to and including but not limited to immediate discharge. 


Clients are NOT permitted to remain on property if they are found to be under the influence or test positive for any prohibited substance. In the event of a relapse, the situation will be handled on a case-by-case basis. Clients will be offered a ride to detox or hospital by staff. Staff will not take clients to an unknown/unsafe location. If a client refuses detox/hospital, then the client will be allowed 30 mins (with staff/house manager supervision) to find a ride away from the property. If a ride is not obtained, further action may be taken up to and including, but not limited to contacting local law enforcement. If a client attempts to operate a vehicle at this time, local law enforcement will be contacted immediately. 

Initials: Initials Text field

Medications:

If a client is taking any medications (prescription or over the counter), these will be REQUIRED to be kept in a locker that is located onsite at all times. A lock will be provided to you. Under no circumstances may a client share or distribute their medications to any other client. Medications must remain in your locker at all times. Storage of medications anywhere else on the property is grounds for termination from the Program.

Medication-Assisted Treatment (MAT)

RMSL does allow MAT. Your regiment must be Dr prescribed. Be aware that RMSL does lab test and monitors your medication levels. If you are a methadone client, you must go to the local clinic to administer your dose. Medications must remain in your locker at all times. Storage of medications anywhere else on the property is grounds for termination from the program.


Rocky Mountain Sober Living LLC does NOT assume any responsibility for lost or stolen medications. Should there be an issue with medications, Rocky Mountain Sober Living LLC will investigate the matter as seen fit and will not reimburse a client for any costs associated with the incident. Rocky Mountain Sober Living LLC staff reserves the right to conduct medication counts at any time. 


In regard to Suboxone, clients on this medication will agree to regular and random medication counts conducted by Rocky Mountain Sober Living LLC staff (or house manager). Should any discrepancy (over or under) occur in the counts, the client will be subject to immediate action up to and including but not limited to investigation and discharge. 


In regard to methadone usage. RMSL requires that you receive your daily dose of Methadone from the local clinic. Storage of Methadone on site is prohibited. 

Initials: Initials Text field

House Meetings/Case Management: 

Clients are required to attend MANDATORY house meetings. The House meeting will be the third week of the month. Meetings Start promptly at 6:30 pm. The client can also expect to meet with the case manager once a week for a status update on your recovery. Should a client need to miss this meeting for any reason, the notification must be given to staff no less than 48 hours prior and must be given approval. 

Initials: Initials Text field

Personal Property/Money: 

Rocky Mountain Sober Living LLC does NOT assume any responsibility and will not reimburse any costs associated with lost, stolen, or damaged personal property. It is the client’s responsibility to maintain and protect all personal items. 


Rocky Mountain Sober Living LLC staff reserves the right to conduct searches of clients' property at any time with or without notice. (this includes vehicles). 


*Note* Any personal property left behind once the client is no longer in the Rocky Mountain Sober Living LLC program will be donated and/or discarded after a period of 72hrs.

Initials: Initials Text field

 

Employment/Volunteering: 

The client is required to obtain and maintain active employment, volunteer, attend school, or any combination thereof within two weeks of admittance. And these must consist of a minimum of 20 hours per week. If not working or volunteering Full time, the client must leave the facility between 9 am and 5 pm. They may return for lunch during the day for no longer than 30 minutes.  The client must keep in mind obligations to attending house meetings, case management, and 12-step/recovery meetings and must balance their work schedule with program obligations. Clients must provide proof of 30 hours for the first 4 weeks. This will be collected at the weekly program meeting. Additional requirements may be required on a case-by-case basis.

Initials: Initials Text field

Recovery:

Clients are required to be working on their recovery. This can be achieved in many ways, 12-step in-person meetings, All Recovery meetings, Professional Therapy, and Peer Coaching; RMSL understands that there are many paths to recovery. We expect your active participation in your recovery. If you are not working on a program, you will be removed from the program.

Initials: Initials Text field

Peer Recovery Coaching & Case Management

Rocky Mountain Sober Living has partnered with Various Organizations to provide peer coaching and case mangement free of charge to our clients. Upon being admitted to RMSL, clients will be assigned a case manager as well as a peer coach with Purple Mountain Recovery. Clients will meet with case management weekly to help assist with any needs or resources clients will need. Clients will be expected to meet with their peer coach weekly to work on recovery. We believe a big part of one's success is for clients to have as much support and resources as possible. 

Initials: Initials Text field

Consent To Background Check:

I, hereby authorize Rocky Mountain Sober Living LLC of 1716 E Yampa St, Colorado Springs, CO 80909, and/or its agents to make an investigation of my background, references, character, past employment, consumer reports, education, and criminal history record information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for acceptance into the RMSL program. A telephone facsimile (fax) or xerographic copy of this consent shall be considered as valid as the original consent.


Print name:Client first nameClient middle nameClient last name DOB:Date


Signature:SignatureDated: Date

 

 

 

 


Phase Program:

Rocky Mountain Sober Living operates on a phase program. We believe this allows you to be in control of your recovery journey. Below is our phase program and what is required to complete each phase. 

Blackout Phase: 1-week min. or until you obtain a full-time or volunteer 20 hours AND obtain a coach, therapist, or sponsor. (must verify both) You must be out of the facility by 9 am and not return until 5 pm daily. Unless volunteering 20 hours a week.

8 pm Curfew
5 meetings per week
No overnights
3 UA per week
2 Breathalyzers per week

Phase 1: (30 days)

10 pm curfew
4 meetings per week
1 overnight per week
2 UA per week
2 Breathalyzers per week

Phase 2: (30 days)

11 pm Curfew
3 meetings per week
1 overnight per week
2 UA per week
2 Breathalyzers per week

Phase 3: (30 days)

12 am Curfew
2 meetings per week
2 overnights per week
1 UA per week, 
1 Breathalyzer per week

Transitional Phase: 

12 am curfew
Meetings based on a recovery plan
Unlimited overnights
1 UA per week
1 Breathalyzer per week


*Phase graduation is based on compliance with all rules and regulations of Rocky Mountain Sober Living. You may not phase up without being current on all money owed. 


Minor Infractions will result in the following phase changes:

1st infraction - Start the current phase over

2nd infraction - Move down one phase

3rd infraction - Move to blackout phase

4th infraction - Termination from the program

Minor Infractions:

Not signing off and completing the daily chore
Not cleaning up after yourself.
Not making your bed
Miss weekly case management meeting
Late on rent.

Major infractions will cause the following phase changes:

1st infraction - Start over at the blackout phase

2nd infraction - Termination from the program

Major Infraction

Missing UA


The following will be cause for immediate termination from the program:

Being late for curfew.
Hot or Diluted UA.
Missing Breathalyzer.
Misuse of Medication.
Lying.
Stealing.
Fighting.
Harassment

Overnights: 

Clients will be allowed to take overnights based on their current phase. These can be used one at a time, with 48hrs notice given to the house manager/staff. If more than 1 overnight is to be used back to back, a minimum of 72 hours notice must be given. Vacations and extended trips must be given a minimum of 2 weeks' notice to the house manager and will require staff approval. You must request an overnight by filling out the request in the app as well as gaining permission from your house manager

*Note* Clients are NOT allowed to miss any program/house meetings or activities as a result of an overnight. It is the client’s responsibility to plan/schedule accordingly. Exceptions will be made on a case-by-case basis at staff discretion. If overnights are taken, then there will be a $5 charge for a UA.

Initials: Initials Text field

Guests:

All guests are allowed in the common areas of the house ONLY. This includes living rooms, garages, front/back yards, restrooms, and smoking areas. Guests are NOT allowed in bedrooms for any reason. Guests are to be out of the house and off the property by 610 pm Daily, with No Exceptions. Guests MUST be sober to visit or be on the property. Rocky Mountain Sober Living LLC reserves the right to subject any guests to a UA/BA test if they are suspected to be under the influence of any substance. If a guest is found to be under the influence or if the guest refuses to submit to a test, the guest will be required to vacate the property immediately. 


Initials: Initials Text field

Fraternization:

There is ZERO TOLERANCE for fraternization and/or sexual activity in the house or on Rocky Mountain Sober Living LLC property. If a client is caught engaging in these behaviors, action up to and including, but not limited to, non-compliance contract, restrictions, and/or immediate discharge will be taken. 

Initials: Initials Text field

Cleanliness/Chores:

Clients are expected to maintain a clean environment. This includes making your bed at the start of each day and cleaning your room, and you will be assigned a house chore that is expected to be completed daily. There will be random inspections, and there will also be a monthly deep clean on the first Sunday of each month. 

Initials: Initials Text field


Rocky Mountain Sober Living LLC Property: 

All property must be treated with respect. Any damage caused to Rocky Mountain Sober Living LLC property will become the financial responsibility of the individual responsible for said damage. ANY theft of Rocky Mountain Sober Living LLC property will result in immediate action up to and including, but not limited to, immediate discharge and/or law enforcement being contacted.


Initials: Initials Text field

Smoking: 

There is NO smoking in the house. There is a designated smoking area in the rear of the house. All smoking should be kept to this area only. There are also designated cigarette disposal receptacles. Cigarette butts and trash MUST be picked up and kept clean. If a client is caught smoking in the house, action up to and including, but not limited to, non-compliance contract, restrictions, and/or immediate discharge will be taken. 

Initials: Initials Text field

  Pets: 

No pets are allowed in the home at any time. If a guest brings a family pet or animal to visit, pets may be allowed in the yards ONLY, and the client MUST clean up after the animals immediately. 

Initials: Initials Text field


Portable/Space Heaters: 

Portable heaters are not permitted for use in the home/bedrooms. 


Initials: Initials Text field


Weapons/Firearms: 

At no time are weapons or firearms permitted to be on or around Rocky Mountain Sober Living LLC property. This includes vehicles. Prohibited weapons include but are not limited to swords, butterfly knives, switchblade knives, brass knuckles, guns of any type, and archery bows/arrows. Failure to comply with this may result in action up to and including, but not limited to, immediate discharge or contacting law enforcement. 

Initials: Initials Text field


Program Discharge: 

If a client fails to comply with any of the above-stated policies, actions up to and including, but not limited to, immediate discharge may be taken. In the event of program discharge, the client will be given 30 minutes to collect all personal belongings and vacate Rocky Mountain Sober Living LLC property. Any belongings not collected in these 30 minutes will need to be collected at a later time which MUST be scheduled with staff within 72 hours. 

Initials: Initials Text field

 

Notice of Confidentiality and Willful Agreement of Terms:

I am voluntarily and willfully entering into an agreement to participate in a drug/alcohol-free environment of the Rocky Mountain Sober Living LLC program. I agree to maintain and contribute to the safety, accountability, and well-being of the environment at all times. I agree to remain compliant with all previously stated policies, and I understand that if I do not remain compliant, I will be discharged from the program, and I will vacate the premises no later than 30 minutes of being asked. 


I understand that I am a member of the Rocky Mountain Sober Living LLC Program and I am not a tenant of the home. I hereby waive all my rights as a tenant per Colo. Rev. Stat. 38-12-101 to 38-12-104; 38-12-301 to 38-12- 905; 38-20-102; 13-40-101 to 13-40-123. 


I agree to continue working on a program of recovery and maintain abstinence from all substances for the duration in which I am a member of the Rocky Mountain Sober Living LLC program. I agree to maintain and protect the confidentiality of all members of the Rocky Mountain Sober Living LLC program. I will not admit to any unknown persons the names, locations, or any other relevant information regarding other clients, Rocky Mountain Sober Living LLC locations, or any other business being conducted. I will NOT use the address for mail, or any other relevant purpose. 


*NOTE* Should I become non-compliant with any of the above-stated policies, this contract shall become null and void. Should I refuse to vacate the property, I will be considered trespassing, and law enforcement will be contacted. 


Sign:SignatureDate:Date

 

FINANCIAL RESPONSIBILITY AGREEMENT 

All parties who sign this agreement acknowledge the responsibility to pay Rocky Mountain Sober Living LLC for all services provided to the above-named client. Responsible parties are personally responsible for the charges to this client's account. 


Full balances on this account are due and payable monthly. Payments must be made at the beginning of the month (1st Sunday) or on the corresponding date of admission and are paying for the month ahead, not the month behind. Payment arrangements may be made with Rocky Mountain Sober Living LLC staff on a case-by-case basis. However, if you fail to comply with the agreed-upon arrangements, Rocky Mountain Sober Living LLC reserves the right to turn your account over to a collection agency. 


I understand that should my account become delinquent, I will be subject to restrictions up to and including, but not limited to, early curfew, visitor/guest limitations, program probation, and program discharge. 


Any inquiries or questions regarding your account can be directed to Mike Mattice at (719) 505-3467.
I attest that I have fully read and understand these policies, and I agree to adhere to the terms within the full agreement.: 

Initials: Initials Text field

I acknowledge that should I become non-compliant with any of the above-stated policies, this contract shall become null and void, and I will be discharged from the program and asked to vacate immediately. Should I refuse to vacate the property, I will be considered trespassing, and law enforcement will be contacted.: 

Initials: Initials Text field