Cledy's House Of Hope
Legacy Sober Living Home Program Application
Applicant Information
Name: Client first nameClient middle nameClient last name
DOB: Client birthdate
Social Security Number: SSN
Street Address: Client Address
Apt#/Unit: Text field
City: Client City State: Client State Zip: Client Zip
Currently Homeless?
Radio buttons
Phone Number: Client phone
Email Address: Client email
Gender: Client gender
Sobriety Date: Date
Currently working a Program? Dropdown
If yes, please list: Text field
Willing to attend Support meetings? Dropdown
Willing to get Sponsor? Dropdown
How many attempts have you made to get clean in the past? Text field
Most clean time attained: Text field
Have you ever been incarcerated? Dropdown
State Incarcerated: Text field
Currently on probation/ parole? Text field
Date of completion: Date
Probation/ Parole Officer Name: Text field
Registered Sex Offender in any State: Dropdown
Currently have DCFS involvement? Dropdown
Are you currently on any prescribed medications? Dropdown
If yes, list all medications below:
Medication
Why are you seeking housing at this time?
Paragraph
List names and dates of any treatment programs, shelters, recovery and halfway houses attended in the last 5 years:
Paragraph
EMERGENCY CONTACT INFORMATION:
Contact Name: Client first nameClient last name
Contact Phone Number: Client phone
Contact E-mail Address: Client email
SUBSTANCE HISTORY
Client substances of choice
Duration of Use: Text field
DISCLAIMER
All applications are subject to a non-refundable $50 application fee, which covers the cost of your background check and drug test upon entering the home. If approved, residents are required to pay a weekly house fee of $150 for the week following their move-in.
I understand my responsibilities as a house member:
1. To actively engage in creating a recovery plan, collaboratively designed with myself and a designated Sauk Valley Voices of Recovery Peer Support Coach.
2. To follow the House Rules and Expectations, which will be provided before move-in.
3. To be responsible for the weekly House Dues of $150.
By signing below, I agree to the following terms and conditions regarding my stay at Cledy's House of Hope - Legacy Sober Living Home Program:
1. Payment of House Dues: I agree to pay my house dues to Cledy's House of Hope every Sunday by 6 pm in advance. I understand that any money I pay for services will be non-refundable in the event of relapse or if I am asked to leave by house leadership for behavioral reasons or violations of House Rules and Expectations. A refund may only be issued if more than one week's payment has been made, and no other refunds will be provided.
2. Personal Items: Cledy's House of Hope reserves the right to remove any personal items of residents who are no longer residing in the home, for any reason.
3. Right to Refuse Services: Cledy's House of Hope reserves the right to decline or refuse services to anyone at any time and for any reason.
4. Background Checks: I authorize Cledy's House of Hope and Sauk Valley Voices of Recovery staff to conduct nationwide background checks, including legal, and sex offender status, both upon application and periodically during my stay. Evidence of violent crime or sex offender status will result in disqualification from continued residence in the home.
5. Certification of Information: I certify that my answers are true and complete to the best of my knowledge.
By signing below, I am confirming that I have read and understand the above policy. I willingly consent to the disclosed policies and procedures listed in regard to services rendered by Cledy's House of Hope- Legacy Sober Living Home Program.
Printed Applicant Name: Text field
Applicant Signature:Signature
Date:Date