Board and Lodging Waitlist/Referral Form
1. Referral Source
Who are you completing this form for today? Dropdown
Best Contact Info if access to Resident is not possible or timely (quick response required): 1. Cell/text number (preferred) 2. Email 3. Landlines (least ideal). (Name/Cell Phone/Email/Landline) Text field
Is the phone number a cell or landline? Text field
2. Potential Resident or Client Details
How long has the potential Resident been sober/what is their sober date? Text field
Requested Home Placement: Dropdown
Treatment Discharge Date (if applicable) Date
Preferred / Requested Move-In Date: Date
MHCP #or PMI # (8-digits) Text field
Social Security Number Text field (to check eligibility)
DOB Text field (to check eligibility)
Current Location (treatment center, sober home, shelter, etc.): Text field
Are you being asked to leave your current sober home? Dropdown
Which Sober Home and Why are you being asked to Leave? Text field
Resident Legal First Name Client first name
Resident Middle InitialClient middle name
Resident Legal Last Name Client last name
Preferred Name / Nickname: Client nickname
Resident Phone Number Client phone
Resident Email Client email
3. Referring Party Details (if not self/resident)
Referrer's Full Name (type Self if you are referring yourself): Text field
Referrer's Email Address: Text field
Referrer's Direct Phone Number: Text field
Organization or Agency Name: Client Referred By
Role (Counselor, Case Manager, Social Worker, etc.):Text field
4. Authorization to Release Information (ROI) for Self-Referrals only
Checkboxes I authorize Stronger Sober House to obtain my comprehensive assessment (including level of care determination) from my current outpatient/IOP provider and my most recent treatment center for the purpose of confirming DHS eligibility. This authorization is valid for up to one (1) year unless revoked in writing and will be handled under HIPAA, 42 CFR Part 2, and Minnesota law. Providers:
Current Outpatient/IOP: Text field
Most Recent Treatment Center: Text field
Potential Resident Signature Signature
5. Board and Lodging Program Eligibility and Requirements
Eligibility: All Four Questions Must Be “Yes.”
Counselors/Case Managers: Please ensure these requirements are fully reviewed with the resident before submitting.
1. Comprehensive Assessment shows a need for residential care—specifically, a score of 4 on one of the last three dimensions (Dimension 4, 5, or 6)?
Note: Fax Comprehensive Assessment with PMI number to 651-262-0388 to confirm eligibilty before admission and before move-in (please include direct email and direct phone number) Dropdown
2. IOP/Treatment: Will the potential resident be participating in 9 or more hours a week of IOP (Telehealth is not allowed? Dropdown
3. Confirmed admission and intake date into an IOP program? Dropdown
IOP Outpatient Program: Text field
Date IOP Started or Scheduled IOP Intake Date: Text field
4. Can the potential resident meet all participation expections listed below? Dropdown
Below are key expectations (full details are in the Board & Lodging Application & Housing Agreement the resident signs before admission):
Abstain from drugs, alcohol, and gambling.
Attend 9+ hours of in-person treatment/IOP weekly (telehealth is not allowed) and remain in good standing with my treatment provider.
Complete 30 hours/week of productive recovery activity, including 2+ recovery meetings; agree to random drug testing.
Attend the mandatory Sunday night house meeting.
Be respectful and contribute to a clean, supportive home
Keep the home tidy and complete assigned daily & weekly chores by Sunday.
Follow curfews (Sun-Thur 10pm; Fri-Sat 12am), visitor rules, and overnight allowances and use OneStep Recovery App for daily check in/out.
Following overnight rules: no overnights in the first 30 days, and a maximum of 2 per month after that.
Have an active phone line to use phone communication tool, WhatsApp and OneStep Recovery App for daily check in/out.
Bringing only 3-4 large bags of clothes or belongings with you into the home and your shared bedroom space. Anything extra will be returned to toss.
Follow all terms in the Board & Lodging Application & Housing Agreement.
6. Admission Details and Additional Information
Is there anything else we should know (physical accommodations, important background information, safety considerations, preferred location, special needs, legal restrictions, mental health needs, etc.)?
Initials Text field I or my referral is not a Sex Offender
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Please type in "Mens Wait List" or "Women's Wait List"
Client categories
7. Referral and Resident Requirements Agreement
I confirm that all information submitted is accurate and that the potential resident meets Board & Lodging eligibility requirements and understands the expectations listed in this form.
Your Contact Name: Text field
Role (Resident / Counselor / Case Manager / Other): Text field
Date: Date
Signature (Resident or Referring Individual):
Signature
8. Outreach
How did you hear about Stronger Sober House? Client Referred By
9. Removal of Wait List / Referral
If you no longer want to stay on the waitlist, please text 651-243-2343 or email us at strongersoberhouse@gmail.com so we can offer the spot to someone with immediate needs as quickly as possible.