Resident Consents and Authorizations
Please enter your full name, exactly as it is recorded in the application.
First Name:
Client first name
Middle Name:
Client middle name
Last Name:
Client last name
Release of Information
I authorize Be Able to communicate with state and government agencies on my behalf for the purpose of obtaining identification documents, vital records, benefits, or other services related to my recovery and stability.
Initials: Initials Text field
I authorize Be Able to communicate with my designated emergency contact(s) and medical providers, including hospitals, detox facilities, rehabilitation programs, and other healthcare providers, as necessary to support my health, safety, and recovery.
Initials: Initials Text field
I authorize Be Able to communicate with my parole officer, probation officer, mentors, sponsors, volunteers, and other recovery support individuals involved in my recovery plan.
Initials: Initials Text field
I authorize Be Able staff to communicate with current or prospective housing providers, landlords, employers, and community partners when necessary to support my housing stability, employment, or recovery goals.
Initials: Initials Text field
I authorize Be Able to use testimonials, success stories, statements, or other information I voluntarily provide for educational, promotional, fundraising, or program awareness purposes.
Initials: Initials Text field
I authorize Be Able to use photographs, video recordings, or other images of me taken during programs, events, or activities for educational, promotional, fundraising, or program awareness purposes.
Initials: Initials Text field
Drug / Alcohol Testing
I hereby consent, upon the request of Be Able staff, to furnish a sample of my urine, saliva samples, breath and/or blood for analysis for a drug and alcohol test. I am fully aware that the results of this test will be retained by Be Able and will become part of my record.
Initials: Initials Text field
I agree to having authorized personnel (l.e. Housing Director, House Lead and/or assigned Mentor) monitor me during the process of providing the urine sample.
Initials: Initials Text field
I understand that if at any time I refuse to submit to a drug or alcohol test, or if I otherwise fail to cooperate with the testing procedures, it will count as a failed test and disciplinary action may be taken.
Initials: Initials Text field
Recovery Environment Safety Measures
Room Inspections
I consent to routine room inspections conducted by Be Home staff or authorized representatives for the purposes of health, safety, maintenance, policy compliance, and the preservation of a recovery-oriented environment. Reasonable efforts will be made to respect my privacy and personal property during inspections.
Initials: Initials Text field
Personal Property Inspections
I understand that Be Home may inspect personal belongings located within the residence when there is reasonable suspicion of prohibited substances, contraband, stolen property, weapons, or other items that may threaten the safety, security, or recovery environment of the residence.
Initials: Initials Text field
Vehicle Inspections
If I store or park a vehicle on Be Home property, I consent to inspection of that vehicle when there is reasonable suspicion that it contains prohibited substances, contraband, stolen property, weapons, or other items that may violate house policies or threaten the safety of residents and staff.
Initials: Initials Text field
Resident Acknowledgement and Understanding
I understand that these measures are intended to promote the safety, well-being, and recovery of all residents and are not intended to be punitive in nature.
Initials: Initials Text field
I acknowledge that I have had the opportunity to ask questions regarding this authorization and understand the expectations associated with residency at Be Home.
Signature:
Signature
Full Name:
Text field
Date:
Date