Board and Lodging Referral Form

1.  Referral Source 
Who are you completing this form for today? Dropdown

2. Potential Resident or Client Details
Requested Home Placement:  Dropdown
Requested Move-In Date:  Date
Where are you Currently Living 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
Legal First Name Client first name
Middle InitialClient middle name
Legal Last Name Client last name
Preferred Name / Nickname:  Client nickname
Phone Number  Client phone
Email Client email

3.  Referring Party Details (if not self)
Referrer's Full Name (type Self if you are referring yourself): Text field
Referrer's Email Address: Text field 
Referrer's Phone Number:  Text field 
Organization or Agency Name: Client Referred By

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
Does the potential resident meet ALL 4 of the eligibility criteria REQUIRED for Board and Lodging (1, 2, 3 AND 4):
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 to 651-262-0388 to confirm eligibilty before admission and before move-in. Dropdown
2.  Will the potential resident be participating in 9 or more hours a week of IOP? Dropdown
3.  Confirmed admission and intake date into an IOP program?  Dropdown
Confirmed Outpatient Program: Text field
Date IOP Started or Scheduled IOP Intake Date:  Text field

4.  Can the potential resident meet all of our participation requirements listed below?  Dropdown
Note: Residents will agree to all terms of the participation agreement. The list below simply highlights a few that help keep our home safe and supportive for everyone. Failure to follow the rules will result in immediate discharge from the program.

Will abstain from drugs, alcohol, and gambling.
Be serious about your recovery, attend at least 2 recovery meetings per week and agree to random drug testing.
Be a good member of the house and treat other residents with respect.
Attend the mandatory Sunday night house meeting.
Keep the home tidy and complete assigned daily & weekly chores by Sunday.
Follow curfews, visitor rules, and overnight allowances.
Use phone communication tool, WhatsApp and OneStep for daily check in/out.
Understand and abide by all terms in our participation agreement (signed before admission).

6.  Admission Details and Additional Information
(Before admission, resident will need completed application, faxed comp assessment with confirmed IOP, and WhatsApp and OneStep apps loaded)
Is there anything else you'd like us to know about this admission and placement (e.g., preferred location, special needs, legal restrictions, mental health supports, etc.)?  
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Please type in "Mens Wait List" or "Womens Wait List"

Client categories

7.  Outreach
How did you hear about Stronger Sober House? Client Referred By