Name: Client first nameClient last name
Phone number: Client phone
Preferred Pro-nouns: Client pronoun
Clients Gender: Client gender
D.O.B: Client birthdate SSN: SSN
Email:Client email
Admin Date/ Desired Entry Date: Client admit date

Planned Exit Date (9 months recommended): Date
Address:Client AddressClient City
State: Client State
Zip: Client Zip
Emergency Contact/Relative:Text field
Phone Number:Client phone
Do we have permission to contact your emergency contact? Checkboxes

How long have you been using alcohol and/or drugs? Text field
How do you identify yourself: Dropdown

History of seizures: Dropdown
List ALL the illicit drugs that you have used in the past 3 years: Text field
What was the last drug used and when: Text field
(This information will be used to determine urinalysis in the future, so be 100% honest)
Sobriety Date (the date of first day 100% without drugs or alcohol): Date

Probation Officer: Text field Phone Number:Client phoneProbation
Wellness Court? Dropdown
Are you on a Court Order/EDO? Dropdown

 

Attorney: Text field  Phone Number: Client phone
Employment: EmploymentHistory Phone Number: Client phone
AA/NA Sponsor: Client sponsor Phone Number: Client phone
Counselor: Text field Phone Number: Client phone
Doctor: Text field Phone Number: Client phone
Marital Status: Client marital status
Prior Treatment facilities or centers: TreatmentCenterHistory
Criminal Record: Criminal History
Do you have ANY mental health issues or diagnosis? Dropdown
If yes, what: Text field

Do you have ANY physical health/medical issues or disabilities?  Dropdown

If yes, what: Text field

Have you been prescribed any medications within 6 months: Dropdown

List ALL medications prescribed in the past 6 months, that you are currently taking, and the last date taken
1. Last taken: Text fieldDate
2. Last taken: Text fieldDate
3. Last taken: Text fieldDate
Are you required to register for any purpose? Dropdown
If yes, why: Text field

Are you a sexual offender? Dropdown

Are there any Restraining Orders against you or by you? Dropdown
Who: Text field
Relationship: Text field

Are you affiliated with anyone in MHA Sober Living? Dropdown
Who: Text field
Relationship: Text field

 

Are you filling this out for an individual? Dropdown
If yes, what is your name? Text field

Are you applying from a facility? (Halfway House, Treatment Facility, Jail, etc..) Text field
What is the best phone number to reach you? Text field

Today's date: Date

GUEST RULES, RESPONSIBILITIES, AND DUTIES

A. Guest Restriction Period Upon Arrival
1. When a Guest first enters MHASL, they are not allowed to leave premises without a Senior House Member or a House Manager for a given period of time.
2. During the first time stay at MHASL, the restriction period will be 14 days.
3. During a second or subsequent stay, or if discharged from MHASL previously, the restriction will be in force for 30 days.
4. Guests must list the person they leave with on the sign-out board and must have
prior approval.
5. A Guest will not have any visitors during Restriction. MHASL can make an exception
for Guests with children.
6. All visits must be approved by the House Manager and must take place in the common area of MHASL or in the backyard.
7. Guests will be staffed before the end of the Restriction Period. The Guest must have:
a. Attained employment in the first ninety days.
b. Find a Home Group and acquire a commitment within the first two weeks.
c. retained a sponsor and have given the House Manager all sponsor contact information within the first two weeks.
8. Management reserves the right to lengthen or place the Guests back on Restriction at any time for the sobriety and safety of the Guests and/or house members.
9. Upon evidence or reasonable suspicion of a relapse, a Guest must leave the premises immediately. Refusal to do so will result in MHASL staff calling Law Enforcement.
10. Guests are not allowed to go to any alcohol-serving or adult entertainmentn establishments while at MHASL including bars, nightclubs or strip clubs, or any
establishment that restricts entry to 21 years. Any questionable establishment should be cleared first with MHASL Staff.
11. Guests are prohibited from entering any casino. The only exception is if the Guest is employed there.

B. Confidentiality
No Guest will disclose any personal, medical, or other information about another Guest or former Guests to anyone as per Health Insurance Portability and Accountability Act (HIPAA) guidelines. The only exception would be in the case of an interview with a Parole, Probation, or Law Enforcement Officer. If the Guest is unsure of the disclosure, they should consult with the Housing Manager and/or the MHASL Case Manager Supervisor.

C. Personally Owned Vehicle (POV)
1. The use of personally owned vehicles will not be permitted for the first 30 days at MHASL.
2. No personal vehicles are to be driven without providing MHASL with proof of a valid license, registration, and proof of insurance on the vehicle to be driven.
3. One vehicle per person is allowed on the property or on the street at MHASL.
4. The POV must be in working condition or it will be towed at owner’s expense.
5. A Guest with a POV is expected to be of service and help other Guests get to required meetings.
6. Guests needing rides from a Guest with a POV should ask 24 hours in advance and are expected to be of service in other ways and/or help pay for gas.

D. Medications
1. The MHASL House Manager must be informed of and must inspect all medications, including both medical/clinical provider prescribed and over the counter (OTC) drugs that a Guest is taking or has in their possession.
2. No medication or drug will be allowed on the premises that the MHASL House Manager is not aware of.
3. Any unlisted or unpresented drugs in the possession of a Guest or Visitor that are found will constitute a violation of this Policy, and the Guest will be discharged.
4. If Guests are prescribed any MHASL approved medications, it is the sole responsibility of the Guest to take the medication as prescribed.

E. Prohibited Medications and Products
1. All medical/clinical provider prescribed medications and or over the counter (OTC) drugs must be checked against the Prohibited Medication List found in Appendix B.
2. Should a Guest be found to be taking a medication, prescribed or OTC, that was not listed in the application and was not reported for inclusion on the Guest’s list of approved medications, the Guest will be discharged.
3. If a Guest, as a result of an appointment, injury or illness, is prescribed a medication that is on the Prohibited Medication List, the MHASL House Manager will immediately consult with the Guest’s Case Manager to determine if the Guest will remain eligible to remain in residence or how to proceed.
4. MHASL reserves the right to confirm ALL medical information with Providers, Dentists, Hospitals, etc., before and during residency at Sober Living. A Release of Information will be obtained by Case Management.
5. Guests may not use mouthwash, or any other product that contains alcohol, this includes beverages labeled as non-alcoholic beer.

F. Appointments for Medical, Dental, or Professional Purposes

Guests must inform management of all pending appointments in advance so if transportation is required, arrangements can be made. If possible, a pass must be approved per Policy.

G. Other Off-premises Personal Appointments, Meetings, Shopping
MHASL does provide transportation with drivers if a Guest needs to be transported to an off-premises destination. Personal needs such as haircuts and shopping, etc. are not, however, a priority. If possible, it is asked that the Guest arrange for their own rides. If a person who is MHASL authorized to drive, has no higher priority tasks, and is willing to be of service, they can accommodate the Guest.

H. Personal Hygiene, Cleanliness and Overall Appearance
Guests will maintain a decent standard of personal hygiene and cleanliness to include:
• Taking a daily shower or bath,
• Maintaining good oral hygiene,
• Washing hands frequently, especially after using the bathroom and before handling food, and
• Keeping clothes, bedding, and the surrounding areas clean and sanitary.
• Guests may not have “hickies” if reported to MHASL Staff, disciplinary action will be taken.
• Guests cannot wear bandanas or clothing that could be interpreted as hateful or harmful or as gang affiliated.

I. Personal Possessions, Area Upkeep and Maintenance
1. Each Guest is allowed the equivalent of two large suitcases of clothing, toiletries, and other personal items. All items left at MHASL thirty (30) days after leaving will be considered a donation. At no time is MHASL responsible for Guests’ belongings.
2. Guests are responsible for protecting their financial resources.
3. Guests are not allowed to borrow money from other guests.
4. Guests are allowed a TV no bigger than 50 inches. This is a privilege, and Guest will be asked to remove it if the Guest does not adhere to house guidelines regarding noise and the disturbance of other Guests.
5. No space heaters, humidifiers, personal refrigerators, etc. are permitted.
6. Guests are responsible for keeping their personal areas neat and clean, including nightstands, dressers, closets, under their bed, etc. Clothing and personal belongings must always be stored neatly.
7. Guests are required to have their bed made, and bedding must be washed a minimum of once a week.
8. Guests will not sleep on the top of the comforter or bedspread or on a couch or the floor.
9. Guests will not change the assigned bed or rearrange furniture without permission from the House Manager.
10. Guests cannot bring in furniture or hang anything on walls without prior approval from the House Manager. Photos, posters, etc. must be placed on each person’s billboard and are not allowed on walls.
11. No eating or drinking (other than water) is permitted in any area other than the kitchen and dining room. Food is not to be left on the counter. All food must be stored appropriately in the refrigerator or cupboard.
12. Thermostats in common areas will be adjusted by the House Manager only.
13. Smoking is not allowed in the house or Lodge at any time and is only permitted in designated smoking areas.
14. There will be no loitering in front of the house.
15. The washer and dryer may only be used from 6:00 a.m. until 10:00 p.m. Loads must be medium to full, but not excessive. If any laundry is left in the machines for longer than 30 minutes, it will be confiscated.

J. Mandatory and Assigned Chores
1. Chores promote personal responsibility. Failure to have chores completed as scheduled will result in a possible strike. Guests will not be allowed to leave the premises until their assigned chores are properly completed. Paying or asking another Guest to complete their chores is not permitted.
2. Guests are expected to be considerate of housemates and clean up after themselves. Example: Guests are responsible for washing their own dishes and cleaning up after cooking.
3. If a Guest must be at work before 7:00 a.m., arrangements can be made to do assigned chores after work, but this must be approved by a House Manager.
4. “Double Scrub” or a thorough cleaning of the entire house will be done monthly, on the last Friday of the month. Couches and chairs, etc. must be pulled out so that the areas behind and under them will be cleaned. Ceiling fans, shelves, trim, appliances, etc. must be cleaned appropriately.

K. Inspections and Access to Guest Information
1. To ensure that MHASL standards and rules are being observed and maintained, all rooms are subject to random inspection for cleanliness and/or contraband. This includes drawers, closets, etc. "Announced," "no-notice," "health and wellness," and "spot check" inspections can be administered.
2. Law Enforcement and Parole/Probation officers are granted physical access to Lodges and to pertinent information on all clients at any time.

L. Curfews
1. Guests are required to adhere to curfew.
2. Curfew is 11:00 p.m., Sunday through Thursday and 12:00 a.m. (Midnight), Friday and Saturday.
3. Adherence to curfew means signing in by the curfew times listed and remaining in-house. Guests are required to sign out when they leave the house and sign in immediately upon return to the house.
4. If an event is scheduled to end beyond curfew time, the Guest must obtain advance approval of the House Manager to attend the event and agree to a return time.
5. Guests must call a House Manager if an emergency arises, or if they are late for curfew.
6. If a Guest is late, a UA and breathalyzer will be given.

M. Quiet Time
1. Quiet time starts at 10:00 p.m. and ends at 6:00 a.m. during the week (Sunday through Thursday). Weekend times will be more lax and discretionary, but a Guest must always restrict noise so as to be respectful of others who may be sleeping or resting.
2. Guests may read or watch television during quiet time if other Guests are not disturbed.

N. Visitation and Personal Relationships
Visitation is a privilege, not a right, granted by the MHASL to eligible Guests.
1. No Guest may date or have romantic or sexual relations with any other MHASL Guest.
2. If a Guest is on probation or parole, they must procure written permission from their presiding office to spend one-on-one time with any individual, outside of MHASL, who is also on probation or parole.
3. Prior to admission to the premises, the Visitor must be approved by MHASL Staff.
4. Visitors of the opposite sex, as a rule, are not allowed in a Lodge. Example: A male visitor will not be granted admission to a female Lodge. Exceptions must be MHASL Staff approved.
5. Visitors must be adults (18 years of age or older) or, if a minor, must be accompanied by a supervising adult.
6. The Visitor must be personally known to and invited by the Guest. MHASL Staff will not allow or escort a Visitor into a Lodge without a Guest host.
7. Visitors, including sponsors, must remain in an indoor or outdoor common area at all times.
8. Visitors are not permitted in another person’s bedroom regardless of their relationship unless accompanied by a House Manager for the purposes of touring or inspecting the bedroom.
9. The Guest will host the Visitor and is responsible for informing them of Lodge policies and procedures and ensuring they abide by them at all times while on the premises. As hosts, Guests are held liable for the conduct of their Visitor and may be subject to disciplinary action if their Visitor violates a policy or procedure.
10. Visitors who intentionally exhibit inappropriate behavior will be required to leave the Lodge and Lodge premises.

O. Visiting Hours
1. Visiting hours are between the hours of 10 a.m. and 10 p.m. Any change in these hours will be made known to Guests prior to or immediately upon implementation.
2. No overnight Visitors are permitted in the MHASL house.
3. If Guests have children, ongoing visitation rules and guidelines will be determined on a case-by-case basis by the Lodge.

P. Weekend Pass
1. After a Guest has completed their restriction period, and is in good standing, they may be granted a weekend pass.
2. The Guest must provide a written request for a Pass to the House Manager no later than 4:30 p.m. Thursday. The request must provide:
a. the date and time of departure from the Lodge,
b. the return date and time,
c. the name and telephone number of the person(s) with whom the Guest is going, and
d. the name, address, and telephone number of planned locations.
3. The Request itself does not constitute permission. The Request is subject to approval before the Guest can leave.
4. All Guests will be subjected to a UA test upon return to the Lodge.

Q. Lodge Transfer
1. When a MHASL Lodge Guest decides they wish to transfer to a different Sober Lodge, they must fill out a request and authorization form. Their request will be staffed MHASL Staff.
2. They will not be allowed to have their phone for 30 days, if accepted into the new Lodge.

R. Disciplinary Measures
Unless specifically referenced as a guideline, the Guest will view all directives within this Policy as a “rule” or a regulation. The severity of the disciplinary action will be determined on an individual basis relative to the detrimental effect the infraction or violation has on the Guest, other Guests, staff, and the Program.
1. Strikes
Breaking any of the rules of the MHASL can result in the Guest receiving a “strike.” If a Guest receives a strike, they will be allotted the standard time of one (1) week to work it off. A longer or shorter timeframe may be given or granted depending upon circumstances. The term of the strike will be made clear to the Guest. The consequences of a strike can be an extra chore and or up to 1-7 days restriction based on the severity of the strike.
a. A strike will be posted if the Guest:
1) is not out of bed on time. The Guest will be given one verbal warning.
2) does not complete an assigned chore before 11a.m. or by an agreed upon deadline,
3) fails to attend the required daily meeting,
4) does not get meeting slips signed,
5) missed any treatment services, Hawkvision appointment, and or any scheduled appointment with MHA Recovery Services without the approval of their Counselor and Case Manager.
6) does not sign in or out when they leave the house,
7) violates curfew or fails to notify the house manager of updated time of return.
8) fails to find a sponsor in two weeks. The Guest will remain on restrictions until such time as the Sponsor is found.
b. If the Guest is routinely and excessively disruptive to the order of the Lodge, they may be discharged if:
1) they have three (3) or more strikes posted in any one 24-hour period, or
2) they have amassed an unreasonable number of strikes in one (1) week,
3) more than one of the infractions is clearly intentional, or
4) any infraction is malicious in nature,
5) their actions may be construed as an indication that the Guest is not committed to the MHASL Program and/or to success in their recovery.
6) Does not return to the Lodge for the night without prior approval from House Manager
A Guest does not work off the strike(s) in an acceptable manner and in the allotted timeframe.
2. Behavioral Contract
A Guest can be placed on a written Behavioral Contract if they receive repeated and unheeded warnings, multiple or excessive strikes, evidence an obvious lack of motivation, and/or show a disregard for compliance with basic Lodge standards for consideration of staff and other Guests. The terms, conditions and length of the Contract will be entirely at the discretion of the MHASL Staff. Failure to comply with the Contract can result in discharge.
3. Discharge by Suspicion
If MHASL Management strongly suspects that a Guest is currently abusing drugs
and/or drinking alcohol, a positive urine result and/or breath test is not required for
discharge.
4. Guest is Asked to Leave a Lodge and the Conditions for Readmission
a) Guests who have been asked to leave for cause have the option to utilize Room and Board through the Good Road Recovery Center during their 72-hour leave.
b) A drug test will be given before the Guest is allowed back into residency. Positive UA readmission (marijuana/false positives) will be determined by MHASL STAFF.
c) The Guest will be allowed back into a MHASL after being clean and sober for 72 hours.
d) After a third positive test, the Guest will be discharged from the residence. In this case, in order for a Guest to return, they must:
e) complete or have an updated evaluation and do what is recommended from that evaluation, and
f) resubmit a new MHASL application. Upon completion of the application, MHASL Managers will review the application, and, if determined eligible, the Applicant/Guest will be added to the waiting list.
g) If the Guest is already on a Behavioral Contract, the “clean and sober” 72-hour rule does not apply. The Guest will be discharged immediately and must wait a minimum of thirty days and no more than ninety days to reapply as described above.

5. Administrative Discharges and Voluntary Walk Offs of Guests Under Court Ordered
Placement or Emergency Detention Order (EDO) (Tribal, State, Or Federal Court
Ordered Placement)
a) The Applicant to MHASL, the Presiding Court Officer, or the Parole/Probation Officer must provide a copy of the Order of Placement at the time of application to the Program. The MHASL Intake Coordinator will upload or ensure that the Order of Placement is in Best Notes. If the Applicant is accepted for residency, MHASL will abide by the Court Order but is not permitted to attempt to uphold the conditions therein that are above or outside of the Policies of the MHASL. Residence in MHASL is voluntary. MHASL Staff will not hold or detain a Guest.
b) In the event a Guest who is ordered to reside at MHASL is discharged for substantial breach of MHASL Policy or elects to leave the house of their own accord, MHASL Staff will follow the procedures listed below.

S. Program Fees
All fees associated with the Program will be explained and expressed in writing so that Guests are aware, informed, and prepared to be responsible for costs. Guests are expected to be self-supporting and must contribute financially to the running of the MHASL Lodge. After a one time forty-five (45) days or approximately one month and fifthteen days of residency in a fiscal year, Guests will be required to pay monthly program fees and/or volunteer for work, actively engage in recovery support and strive for overall health and wellness. Upon securing income, Guests will be expected to pay program fees.
1. Program Fees
Program fees are due the first of the month in the amount of $250. Payment arrangements can be made if Guest is not able to pay the full amount on the first of the month. Payment will be issued to MHA Sober Living in the form of a money order or cashier’s check. Should the first of the month fall on a weekend, fees will be due on the first day of the following week.
Should a Guest fail to pay:
a. weekend passes will not be granted.
b. restrictions will be given, and not lifted until rent is brought up to date.
c. a team administrative meeting will be convened to discuss and resolve the issue. The Guest will need to provide a budget along with check stubs to show where money is going.
d. Refunds will not be given for Program Fees.
2. Key Card Replacement Fee
Guests will be provided with a key card for the living space and entry to the Lodge. The initial card will be given free of charge upon entry into the Program. If the Guest
needs a replacement card, there will be a fee of $ 25 for issuance of a replacement card.
3. Drug Testing Fees
Guests are responsible for one half of the cost of each drug test administered.
The current cost to the Guest is $10 per test.
4. Guest Damage Fee
The Guest will incur a fee for any assessed damage to the Lodge. The cost will be determined by the damage replacement cost and will be charged to the Guest.

T. Paid Work Agreement
Guests entering a MHASL work agreement do so on a voluntary basis.
1. Guests are protected from suffering consequences if they elect not to enter into a Paid Work Agreement.
2. Guests who accept paid work are not treated more favorably than Guests who do not.
3. All qualified Guests are given equal opportunity for available work.
4. Paid work for the operator or staff does not impair participating Guest’s progress towards recovery goals.
5. The work rendered is treated the same as any other employment situation.
6. Wages will be commensurate with the marketplace value and at least minimum wage.
7. The arrangements must be viewed by a majority of the Guests as fair.
8. Work relationships must not negatively affect the recovery environment or morale of the house.
9. Unsatisfactory work relationships will be terminated without recrimination that can impair recovery.

U. GRIEVANCE APPEALS AND PROCEDURE:
MHA Sober Living has established a procedure for the resolution of a guest’s grievance when submitted to the MHA Sober Living staff. Filing a grievance will not negatively affect the
guest’s status or future status in the home. Grievances can be submitted by a guest within five days of the incident and will be reviewed by MHA Sober Living’s Case Manager Supervisor.

PROCEDURES:
1. Grievances can be submitted to MHA Sober Living by any source, including anonymous
reporters. Grievances will be written and submitted to MHA Sober Living Case Management
Supervisor.
a. All information regarding a grievance will be documented using a grievance form.
b. A written grievance form and written grievances submitted will be kept on file.
2. An attempt must be made to resolve the grievance verbally between the guest and guest’s House Manger.
a. If the grievance is not or cannot be satisfied after the first step, a written formal complaint can be filed. The guest can express formally how they feel they have been discriminated against or treated unfairly. Guests must cite which policy was violated.
3. The grievance will be submitted to MHASL Case Management.
a. MHASL Case Manager will review the submitted documentation. A mediation time will be scheduled between the guest and the Lead House Manager, or the involved parties.
b. If the issue has not been resolved through the mediation process, MHASL Assistant Supervisor will be informed.
4. MHA Assistant Supervisor will review grievance documentation and mediation meeting notes and will submit final decision based on MHASL Policy to MHASL Supervisor.
5. MHASL Assistant Supervisor and MHASL will present guest with the final decision.
a. While the grievance is being assessed, the individual must continue to comply with all terms of MHA Sober Living.
6. In the event a Guest feels dissatisfied with any service provided to them, they are encouraged to discuss this with the person providing the services. If the individual is still dissatisfied, they may have a conference with the supervisor of the individual providing the services or with the MHASL Supervisor. If the issue is still unable to be resolved, then they may have a conference with the Executive Director of MHA Recovery Services. If the individual is still not satisfied or the issue is not a complaint can be made to the appropriate tribal entity.

 

 Name: Text field

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