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.
Which location are you applying for?
Personal Information-
Anticipated move in date:
Where are you moving from:
Full name:
Prefered name:
Date of birth:
Contact info:
Emergency Contact:
Second contact:
Do you have a vehicle:
Auto Make, Model and License Plate Number:
Driver’s License Number and State:
Do you smoke tobacco/ vape?
Do you have and plan to utilize a medical cannabis card?
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.
Do you have any immediate needs such as clothing or toiletries?
Do you need assistance with any self-help, support group and/or networks within the local community?
Do you need help to renew any forms of identification?
Do you need assistance with any food programs?
Criminal history-
Do you have a criminal history of violence or sexual crimes?
What were your most recent charges:
Do you have Criminal Justice involvement? (If Yes, provide name of P/O, Number, county)
Do you have any upcoming court date? If yes, what county and date: date:
Recovery Information-
What is the last treatment you attended? / Did you complete the program?
Have you lived in sober housing before? / If yes, please list the last one you resided in: When did you graduate?
Substance of choice:
Don't see the option you're looking for? Click here Don't see the option you're looking for? Click here Don't see the option you're looking for? Click here What is your last date of use?
What is your longest period of sobriety?
Do you have a sponsor/ mentor:
Do you have a CPRS/ Recovery Coats:
If no, are you interested in working with one?
Medications and health conditions-
Are you currently prescribed medications:
Medications:
Are you participating in or about to enter any drug replacement program?
If yes, what are they:
Medical concerns:
Don't see the option you're looking for? Click here Allergies that we need to be aware of?
Are you currently under the care of any of the following provider types:
None Applicable
Medical Doctor (PCP)
Psychiatrist
Psychologist
Therapist
Nutritionist
Employment Information:
Are you currently employed (Y/N)
, If no are you planning to find employment
Employer’s Name/ address/ Phone number/ Scheduled hours working:
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.
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.
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.
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.
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.
5. 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.
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.
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?
Sign & Date