AGAPE RECOVERY HOUSE Intake
First Name: Resident first name
Middle Name: Resident middle name
Last Name: Resident last name
Mailing Address
Resident mailing address
Email: Resident email Phone Number: Resident phone
Gender: Resident gender Birthdate: Resident birthdate
School: Resident school
Current Employment: Resident current employment
Occupation: Resident occupation
Marital status: Resident marital status
Race: Resident race
Veteran: Resident veteran status
Payment Payer: Text field
Payment Amount: Text field
Payment Frequency: Resident payment frequency
Contacts
Contact #1
Name: Contact 1 name Phone: Contact 1 phone
Type: Contact 1 type Email: Contact 1 email
Contact #2
Name: Contact 2 name Phone: Contact 2 phone
Type: Contact 2 type Email: Contact 2 email
Contact #3
Name: Contact 3 name Phone: Contact 3 phone
Type: Contact 3 type Email: Contact 3 email
Contact #4
Name: Contact 4 name Phone: Contact 4 phone
Type: Contact 4 type Email: Contact 4 email
Contact #5
Name: Contact 5 name Phone: Contact 5 phone
Type: Contact 5 type Email: Contact 5 email
Health Insurance
Provider: Resident insurance provider Insurance Plan: Resident insurance plan
Group ID: Resident insurance group ID Policy#: Resident insurance policy #
House Information
House: Resident house Move In Date: Resident move in date
Estimated Length of Stay: Resident estimated length of stay
Room Number: Resident room number Bed Number: Resident bed number
Status: Resident status Sobriety Date: Resident sobriety date
Level/Phase: Resident level/phase Move out Date: Resident move out date
IOP: Resident IOP
Medical History
Diagnosis: Resident diagnosis Substance of Choice: Resident substance of choice
Allergies: Resident allergies Relapse Date: Resident relapse date
Referred by: Resident referred by
Treatment Centers
Treatment Center #1
Name: Treatment center 1 name
Started: Treatment center 1 started Ended: Treatment center 1 ended
Notes: Treatment center 1 notes
Treatment Center #2
Name: Treatment center 2 name
Started: Treatment center 2 started Ended: Treatment center 2 ended
Notes: Treatment center 2 notes
Treatment Center #3
Name: Treatment center 3 name
Started: Treatment center 3 started Ended: Treatment center 3 ended
Notes: Treatment center 3 notes
Treatment Center #4
Name: Treatment center 4 name
Started: Treatment center 4 started Ended: Treatment center 4 ended
Notes: Treatment center 4 notes
Treatment Center #5
Name: Treatment center 5 name
Started: Treatment center 5 started Ended: Treatment center 5 ended
Notes: Treatment center 5 notes
Screening Questions
What is your sober date? Paragraph
When do you plan on moving? Paragraph
Is this your only option? (moving into sober housing) Paragraph
Are you looking into other Sober Houses? Paragraph
How many times have you completed treatment? Paragraph
Are you planning on attending outpatient? Paragraph
What meds are you taking?
Medication #1
Medication: Medication 1 name Dosage: Medication 1 dosage
Quantity: Medication 1 quantity Category: Medication 1 category
Frequency: Medication 1 frequency MD: Medication 1 md
Notes: Medication 1 notes
Medication #2
Medication: Medication 2 name Dosage: Medication 2 dosage
Quantity: Medication 2 quantity Category: Medication 2 category
Frequency: Medication 2 frequency MD: Medication 2 md
Notes: Medication 2 notes
Medication #3
Medication: Medication 3 name Dosage: Medication 3 dosage
Quantity: Medication 3 quantity Category: Medication 3 category
Frequency: Medication 3 frequency MD: Medication 3 md
Notes: Medication 3 notes
Medication #4
Medication: Medication 4 name Dosage: Medication 4 dosage
Quantity: Medication 4 quantity Category: Medication 4 category
Frequency: Medication 4 frequency MD: Medication 4 md
Notes: Medication 4 notes
Medication #5
Medication: Medication 5 name Dosage: Medication 5 dosage
Quantity: Medication 5 quantity Category: Medication 5 category
Frequency: Medication 5 frequency MD: Medication 5 md
Notes: Medication 5 notes
Give me a snapshot of your history (not the whole story) Paragraph
Are you in a relationship? (if not mentioned) Text field
Are you self-supporting? How? Paragraph
Are you able to pay the program fee? (and deposit to hold bed, etc.) Text field
Do you drive? Text field
Do you have a sponsor? If so, are you working steps? Text field
Mission:
AGAPE RECOVERY House provides a quality sober living environment for women who are ambitious about recovery. We pride ourselves on being trauma informed and using a holistic wellness approach that is vital to your personal transformation. We look forward to being part of your journey of sobriety and prosperity.
House expectations/requirements
- Sober for at least 30 days
- Ability to strive in group living environment
- Attend a minimum of 1 outside meetings (AA, NA, 12 step)
- Attend mandatory house meeting each week
- Work, attend school or volunteer for at least 20 hours each week
- Overnight guest not allowed
- Visitors welcomed during visiting hours
- Work with a sponsor weekly
- No male guest allowed unless prior authorization is given
- Minimum of a three month stay required
Resident Agreement:
Program Fees: Residents will occupy a single room at $710.00 per month. Each resident will be required to pay a sober deposit of $300.00. Program fee is due by the 3rd day of each month. If a resident moves into the house after the first of the month, the program fee will be required in full prior to move in on a prorated basis. If a resident moves out before the end of the month, no portion of the program fee will be refunded. One month notice is required prior to date of departure and departure can only take place the last day of each month; the contract is month-to-month. If a resident chooses to depart prior to the last day of the month, they will forfeit the remainder of month’s program fee.
Sober Deposit: The sober deposit is returned upon a satisfactory departure. If a resident drinks or uses or violates any of the rules as specified in this contract, they will automatically forfeit their deposit. Deposit will not be returned if client departs for any reason, voluntary or involuntary, before the minimum stay requirement. The house must be in the same condition as when resident moved in, including removing all personal items (including food), completing that week’s chore, cleaning room thoroughly, and doing all linens. Residents must leave house linens (sheets, towels, etc.) in order to receive sober deposit.
Off Street Parking: AGAPE HOUSE is located at 889 4th Street E - Unit 1, St. Paul, MN 55106 - There are no off street parking spots, street parking is available.
Attitude: AGAPE HOUSE is a sober, trauma-informed, community living environment. It is necessary to abide by set rules and guidelines to maintain order and reduce conflict or confusion. It is equally important that AGAPE HOUSE residents have the ability to work together as a team and support one another in the journey to living a responsible life guided by spiritual principals. It is impossible to foresee every situation that might arise so please remember this when issues come up.
Living Quarters: Residents are responsible for preparing their own meals, maintaining a clean living environment, purchasing their own groceries, and participating in weekly house chores. Division of chores can be found in the house binder. Residents will be provided access to a washer & dryer free, towels, linen and bedding. Residents are expected to purchase their own personal hygiene products.
Drug and Alcohol Use: The house is to be drug and alcohol free with no exceptions. If any resident is found with drugs or alcohol or is suspected of having these substances, local law enforcement will be notified. Residents who use drugs or alcohol will be required to leave the premises until they are completely sober. Residents will be allowed back in the house on a case by case basis. All residents are expected to report any use or suspected use to the owner and/or house manager immediately.
UA’s and BAC: AGAPE HOUSE can and will administer UA’s or BAC randomly or on an as needed base.
Weekly House Meeting: All residents will participate in a weekly house meeting with the house manager and/or owner of AGAPE HOUSE. The purpose of this meeting is to discuss house related business and conduct resident check-ins. All residents are expected to participate in check-ins. House meetings are mandatory and are scheduled a week in advance.
Sexual Activity: No sexual activity is permitted between residents or guests.
Weapons: Weapons are prohibited.
Intimidation/Violence: AGAPE HOUSE has a zero tolerance policy for any type of violence or intimidation and is grounds for immediate discharge.
Curfew: All residents will be expected to return to the house by 11:00pm Sunday through Thursday and 12:00am Friday and Saturdays.
Overnights: Residents must be in the house for 2 full weeks before their first overnight, at which time, they may have 2 overnight per week. After 1 month in the house, residents may have 4 overnights per week. Residents are encouraged to plan ahead and must provide house manager with overnight plans for the week by the House Meeting. Please inform/remind roommates by 7:00pm that you are not coming home on nights you are having an overnight. House managers reserve the right to suspend overnight privileges in cases where overnight privileges have been abused or resident is not meeting house expectations.
Visitation: Visitors may only visit during visiting hours and may only visit in common areas on the main area of the house. Visitors are allowed to stay for up to 2 hours at a time and may not be left unaccompanied.
Visiting hours are as follows:
Monday – Friday 10:00 am to 8:00pm
Saturday and Sunday 12:00pm to 8:00pm
Medication: AGAPE HOUSE does not dispense medication nor are they responsible for medication. Residents are encouraged to take all medications as prescribed by their medical doctors and psychiatrists. Mood altering medications are strictly prohibited. No narcotic medications are allowed. Do not fill these prescriptions! There is absolutely no med sharing; all meds need to be locked in a lockbox safely put away. Medication that is lost or stolen should be reported to house manager or owner immediately.
Smoking: Smoking is permitted on the patio and in the back of the house. ABSOLUTELY NO smoking in the house, or on the front stoop.
House Liability: Residents are discouraged from bringing personal items of value over $50 into the home. Game systems, jewelry, laptops, expensive clothing, and other valuables should not be brought into the home. Residents sign a waiver that states that staff persons are not responsible for lost or stolen personal items. AGAPE HOUSE is not liable for any personal property during or after the resident’s discharge from the house. AGAPE HOUSE will dispose of all personal property after 30 days of discharge from the program unless other arrangements have been agreed upon. AGAPE HOUSE assumes no responsibility for the personal property of residents.
No Resident Will: Install anything on floor, walls, ceilings, windows, doors, or outside of home. Residents will not drill or attach items to walls. Each resident will be allowed to put their own picture frames and personal items on flat surfaces in their room.
Music: Please be respectful of your housemates by keeping your music at a level that can be heard only by you. Headphones, iPods, etc. are encouraged.
Housekeeping: Each resident will be responsible to complete house chores on a weekly basis. Residents will be assigned chores monthly and will be responsible for that chore for the entire month. Chores will include, but are not limited to include: kitchen, bathroom, dining room/hall, living room/entry, laundry/stairs, and yard. Residents are responsible for their own areas. Residents agree to keep their bedroom neat and tidy, do their own laundry, do dishes immediately after use, keep bathroom items in the designated location, and pick up after themselves in community living areas.
Utilities: It is the expectation that each resident at AGAPE HOUSE will conserve energy and practice the concepts of “reduce, reuse, and recycle” whenever possible. Residents agree to turn off lights when not in use, do only full loads of laundry, and keep the house at a temperature no greater than 72 degrees in the winter. Residents will not have hot plates, microwaves, space heaters, air conditioners, small or large appliances in their personal rooms. Also, please dispose of all feminine products in the trash can, not the toilet, including tampons.
Out of Bounds: Residents are encouraged to visit non-roommates in common areas, versus visiting in each other’s rooms.
Productivity: Residents are encouraged to be productive and are expected to be have at least 25 hours of productivity hours per week. Productivity includes Work, school, volunteer, 12-step meetings and meeting with sponsor. All sobriety commitments should take priority.
Sleeping: Please do not sleep in the living room.
Self Help Groups: Attendance at least two or more AA, NA, CA, DRA, OA, Al-Anon, Women for Sobriety, Church Recovery Group, or other self-help group meetings is expected on a weekly basis.
Sponsors: All residents will have a sponsor, spiritual advisor, mentor, or recovery guide whom they meet with on a regular weekly basis.
Outpatient Treatment Programs: Each resident is responsible to attend any professional obligations while living at AGAPE HOUSE. These professional appointments will vary based on each individual resident but may include: therapy, psychiatry, medical appointments, court/probation appointments, outpatient treatment, recovery maintenance, and any other appointments.
Telephones: Each resident is responsible to have their own cell phone. There is a house phone available at AGAPE HOUSE.
Healthy Lifestyle: AGAPE HOUSE encourages residents to eat three nutritious meals daily, exercise twice weekly, get 7-9 hours of sleep each night, take medications as prescribed, and have good personal hygiene.
Notice to Vacate: This is not a standard landlord/tenant agreement; this is a sober housing contract. The owner of AGAPE HOUSE may at any time and for any reason ask any resident to immediately vacate the property. Typical reasons a resident may be asked to leave include use of a mood altering chemical, non- payment of program fee, lack of follow through on program rules and expectations, violence toward self or others.
Problem Resolution: If there are any problems between residents it is expected that these will be discussed directly, openly, and honestly in the weekly house meeting or before if the residents are comfortable doing so. Gossip between residents or residents to owner/house manager is prohibited. Problems will be resolved respectfully by each party stating their perspective and feeling and each party coming to some sort of agreement.
I have read and understand AGAPE HOUSE policies, procedures, rules, and expectations. I am hereby making a commitment to follow them for the purpose of housing and recovery:
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Printed name of Resident: Resident first name Resident last name
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Signature of Resident: Signature
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Date: Date
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Signature of Owner/ House Manager: Signature
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Date: Date
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