Resident Applicate-
To be accepted into Hope Recovery housing, this application and a phone interview process must be completed. Carefully read this application and answer all questions that apply to you to the best of your ability. This information is and will remain confidential and be available only to the management of Hope Recovery LLC.
Our requirements are simple! Don’t use, be respectful, and get involved in recovery! We want you to learn to live a healthy life in recovery and move to the next step in your life!
I consent to be contacted by Hope Recovery LLC via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
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Which location are you applying for? Dropdown
Personal Information-
Anticipated move in date:Date
Where are you moving from: Text field
Full name: Client first nameClient last name
Prefered name: Client first name
Date of birth:Client birthdate
Contact info: Client phone Client email
Client Address Client City Client State Client Zip
Emergency Contact: Client first nameClient last nameClient phone
Second contact: Client first nameClient last nameClient phone
Do you have a vehicle: Checkboxes
Auto Make, Model and License Plate Number: Text field
Driver’s License Number and State: Text field
Do you smoke tobacco/ vape? Checkboxes
Do you have and plan to utilize a medical cannabis card? Text field
If yes, understand that Hope Recovery only allows the following forms of Cannabis (Orderless/ Smell Free forms only- Edible form, Lozenges, pill form, some vape forms). We ask that you use all your medication in a discreet manner. By initialing this, I agree to use the allowed forms of cannabis, provide proof of canabis card and proof of purchase from a dispensary. Initials Text field
Do you have any immediate needs such as clothing or toiletries? Checkboxes
Do you need assistance with any self-help, support group and/or networks within the local community? Checkboxes
Do you need help to renew any forms of identification? Checkboxes
Do you need assistance with any food programs? Checkboxes
Criminal history-
Do you have a criminal history of violence or sexual crimes? Checkboxes
What were your most recent charges: Text field
Do you have Criminal Justice involvement? Checkboxes(If Yes, provide name of P/O, Number, county) Paragraph
Do you have any upcoming court date? Checkboxes If yes, what county and date: Text field date: Date
Recovery Information-
What is the last treatment you attended? Text field/ Did you complete the program? Text field
Have you lived in sober housing before? Text field / If yes, please list the last one you resided in: Text field When did you graduate? Client discharge date
Substance of choice:
Client substances of choice
Client substances of choice
Client substances of choice
What is your last date of use? Date
What is your longest period of sobriety? Text field
Do you have a sponsor/ mentor: Checkboxes
Do you have a CPRS/ Recovery Coats: Checkboxes
If no, are you interested in working with one? Checkboxes
Medications and health conditions-
Are you currently prescribed medications: Checkboxes
Medications: Medication
Are you participating in or about to enter any drug replacement program?
Checkboxes
If yes, what are they: Text field
Medical concerns:
Client health problems
Allergies that we need to be aware of?
Text field
Are you currently under the care of any of the following provider types:
Radio buttons None Applicable
Radio buttons Medical Doctor (PCP)
Radio buttons Psychiatrist
Radio buttons Psychologist
Radio buttons Therapist
Dropdown Nutritionist
Employment Information:
Are you currently employed (Y/N) Checkboxes, If no are you planning to find employment Text field
Employer’s Name/ address/ Phone number/ Scheduled hours working:
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Acknowledgement & Agreement:
This is a legal and binding agreement, Please read it carefully: Please initial all, if you have questions, leave blank and we will discuss during phone interview.
Initials Text field 1. I have carefully read and truthfully answered all applicable questions above. I agree to provide an update on information if any of my answers change while I am a resident of Hope Recovery.
Initials Text field 2. I acknowledge that Hope Recovery is a recovery living environment and was established in compliance with the conditions of Minn. Stat. § 254B.181, Subd. 2. Bill of rights. An individual living in a sober home has the right to:
(1) have access to an environment that supports recovery;
(2) have access to an environment that is safe and free from alcohol and other illicit drugs or substances;
(3) be free from physical and verbal abuse, neglect, financial exploitation, and all forms of maltreatment covered under the Vulnerable Adults Act, sections 626.557 to 626.5572;
(4) be treated with dignity and respect and to have personal property treated with respect;
(5) have personal, financial, and medical information kept private and to be advised of the sober home's policies and procedures regarding disclosure of such information;
(6) access, while living in the residence, to other community-based support services as needed;
(7) be referred to appropriate services upon leaving the residence, if necessary;
(8) retain personal property that does not jeopardize safety or health;
(9) assert these rights personally or have them asserted by the individual's representative or by anyone on behalf of the individual without retaliation;
(10) be provided with the name, address, and telephone number of the ombudsman for mental health, substance use disorder, and developmental disabilities and information about the right to file a complaint;
(11) be fully informed of these rights and responsibilities, as well as program policies and procedures; and
(12) not be required to perform services for the residence that are not included in the usual expectations for all residents.
Initials Text field 3. I understand and agree I am a participant in a recovery housing program and not a tenant. I understand that recovery housing residents are not protected by local landlord/ tenant rights and laws. If it is found that a local landlord tenant laws apply, I hereby renounce any rights that I may or may not have.
Initials Text field 4. I agree that I will participate in the program of Hope Recovery living and will abide by all of it’s rules and expectations.
Initials Text field5. I agree that if I violate any of the rules of Hope Recovery, I can be asked to leave housing and forfeit any rights to my sober housing fees paid to that date, which may include a deposit if required prior to move in.
Initials Text field 6. In accordance with state and federal law, Hope Recovery does not discriminate based upon race, religion, sexual orientation, gender, national origin, disability, HIV/AID/ Hepatitis status. By initialing, I agree to the non- discriminant policy and acknowledge that I may be living in the same house as a member of a protected group.
Initials Text field 7. I agree that I am responsible for my own valuables and other personal property during and after my stay at Hope Recovery.
Anything else we should know?
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Sign & Date
Signature Date