Agreement Intake Form

Hazelbrook Sober Living
Resident Agreement

 

***COVID19 Advisement and Policy***

Due to current state of affairs we must ask all new intakes following questions: (If answer is yes please tell Senior Resident IMMEDIATLY prior to doing anything else

1: Have you been out of the country in last 14 day? Radio buttons

2: Have you had a fever in last 14 days? Radio buttons

3: Do you have preexisting respiratory or immune conditions or have diabetes? Radio buttons

 

We wanted to take a moment to assure you that we are actively monitoring the ever-evolving situation surrounding COVID-19. As sober living housing providers we find ourselves in unchartered and unique territory as the health and well-being of our community is a top priority and, we are committed to preventing the spread of this virus amongst not only our community but recovery community as a whole. Hazelbrook Sober Living has been a place of safety and trust and we hold that trust sacred! We will continue to operate and provide safe sober housing and high quality recovery services to our residents but we do want to implement some enhanced safety procedures and protocols:

·        No outside visitors are allowed inside Hazelbrook houses

·        No one is to leave house unless for officially deemed essential tasks.

.        If you do leave house, when you come back you are to immediately wash hands with antibacterial soap and hot water for at least 30 seconds and sanitize anything you touched before wasting hands (such as door knobs)

·        No inter-house meetings are allowed or inter-house visiting. Meaning, no one is allowed to go inside another Hazelbrook House that they are not a resident of.

·        Increased sanitary requirements especially in public areas: All bathrooms, kitchen counters and tables, sinks, toilets, and door knobs are to be sanitized AT LEAST ONCE A DAY!

·        All outside meeting requirements are cancelled and forbidden until further. You may attend virtual recovery meetings. (*This means ONLY Hazelbrook requirements, if you are required to attend meetings or treatment per court order or per any other requirements that is between you and said organization)

·        All residents are encouraged to avoid close interaction amongst residents, and should wear face masks as advised by government

·        If you experience any flu-like symptoms or shortness of breath or fever please notify Senior Resident at your house and immediately contact doctor and schedule appointment to receive Professional Medical Advice as to what you should do and how you should handle situation. According to the Centers for Disease Control (CDC), symptoms largely consist of fever, cough, and shortness of breath. In an effort to protect our staff and residents, if you have been experiencing these symptoms please call 303-343-7072 to schedule your appointment with as much advance notice as possible.

·        If you are required to be quarantined then you must remain quarantined and not contaminate other residents at house an follow Hazelbrook quarnatine instructions.

 

.        Refusal to comply with Hazelbrook Corona Virus Policies or failure to practice government advised safety requirements around social distancing could result in punative actions and potential discharge

 

Text fieldBy initialing here I am acknowledging that I have read and been advised of Hazelbrook Sober Living's policies and safety procedures and rules surrounding this current situation and that if I fail to do this I am doing so against the advise and requirements of Hazelbrook Sober Living. 

Also, please understand that being in a sober living home we are in a unique situation because we are in a group living environment and are in close proximity with other residents. We are doing everything we can to manage this situation and keep everyone safe but being around people to an extent is unavoidable. We strongly advise everyone to stay to themselves, stay in their room as much as possible and avoid close contact with others. We cannot force everyone to stay in their rooms (unless quarantined) but we strongly advise everyone to personally do their best to do this.

Thank you all for your understanding and cooperation in helping us uphold safety of our community and safety navigate this situation. We ask that PLEASE do your best to be as hygienic, sanitary, and considerate of others as possible. If you do feel like you are having sypmtoms PLEASE do not be irresponsible and inconsiderate and try to hide it or not address it. We are not trying to cause a panic or worry and are sure everything will be ok and will be back to nornal soon but what we are trying to do is be responsible and rather err on side of caution then be careless and create a situation where people end up without a safe place to live and work on their recovery.

 

Warm regards,

Alexandra Shvedov – Owner

Hazelbrook Sober Living

Please sign to acknowledge you recieved copy of this and have read and understood and agree to this advisement

 Signature

Thanks and stay healthy!

__________________________________________________________________________________

 

This Residential Living Agreement is entered upon on Date by and between Hazelbrook Sober
Living, LLC (hereinafter “Hazelbrook”) and Client first name Client last name (hereinafter
“Resident”), and shall govern Resident’s living and participation in the sober living program known as
Hazelbrook Sober Living located at Text field.

Full Name:
Client first name Client last name
Date of Birth: Client birthdate
Phone #: Client phone
Email Address* (must have valid and accessible for financial correspondence putting N/A is not an option, if you dont have one make one): Client email
ID/Driver’s License (#/State): Text field

Facility* (MUST ENTER HOUSE, ask Senior Resident if you dont know): Client facility

Admit Date: Client admit date

 

Initial payment info: Text field 

(You must have initial payment in order to move in. If you are recieving funding assistance written verification must be provided to Senior Resident prior to moving in. If you are receiving WAGEES assistance you are required to compete "WAGEES Funding Form" in addition to this Intake prior to move in.) 

WAGEES Funding Form

 Hazelbrook Sober Living Orientation:

All new residents must attend an orientation the Sunday the week they move in. Orientation will be held at Paradigm1 Every Sunday at 1pm. Paradigm1 is located at 16736 E Iliff Ave, Aurora, CO 80013. Please contact Jackie at 720-909-4777 to let her know your name, and that you will be at the orientation on Sunday!

Please sign and date to acknowledge you have read and will attend orientation on Sunday at 1pm

SignatureDate

 

Emergency Contact Info:

Name: Contact 1 name Phone: Contact 1 phone

Relationship: Contact 1 type Email: Contact 1 email

Probation/Parole Officer & County: Contact 2 name

Phone: Contact 2 phone

Email: Contact 2 email

Are you a registered sex offender? 

Radio buttons

Please read CAREFULLY and initial to indicate your understanding and agreement:

Text field I realize that the Hazelbrook Sober Living Program for which I am applying for residency requires
complete abstinence from Drugs and/or Alcohol. Any use of Drugs and/or Alcohol is strictly prohibited
and will result in immediate eviction from our residence(s). Disruptive and/or Discourteous behavior
within our residence(s) or community will not be tolerated and can/will result in discharge from our
program. Finally, a resident’s inability to pay his/her program dues in a timely manner can/will result in
discharge from our program

Text field I understand that as a resident of Hazelbrook Sober Living Program that I am living in an alcohol
and drug free shared housing property managed by a house manager. I also understand that residency
in any Hazelbrook Sober Living, LLC owned, managed, or leased property is in the capacity of a Program
Participant sharing a housing unit and not a tenant with tenant rights or possession of space exclusively.

Text field Residents are required to submit to a Drug and Alcohol Screen/Test at any time (24/7) it is
requested. A refusal and/or failure to provide an adequate sample will be treated the same as a positive
test result. Any attempt to cheat/circumvent test will result in discharge.

Text field I understand that in the event of a positive UA/BA I will have 30 minutes to leave the premises and
will not be able to return for any reason without being accompanied by Hazelbrook Sober Living
management.

Text field I understand that if I leave the house for any reason I will have 2 weeks to arrange pick up or
shipment of my personal belongings. If I do not do so within 2 weeks my belongings will be donated.

Text field I understand that in order for a place to be held for me at the Hazelbrook Sober Living Program a
deposit is required. This deposit is used to hold a place for me and upon move in this deposit will go
towards intake fee. If I for any reason I change my mind prior to scheduled move-in date then this
deposit will be forfeited.

Text field The Hazelbrook Sober Living Program requires a minimum commitment of 90 days. Resident agrees
to stay for minimum of 90 day period and assumes liability for this period, unless otherwise agreed upon
in writing. After initial 90 days residents can stay as long as they are in compliance with Program.

Text field The Hazelbrook Sober Living Program requires a $150.00 intake fee. If a resident leaves the
program or is terminated for any reason or relapses they will be required to pay intake fee again.

Text field Program fees are $200.00 weekly OR $750.00 monthly. (Dues must be paid IN FULL and ON TIME
in order to receive rate of $750/month.) Program dues are to be paid for upcoming week/month (i.e.,
dues paid on July 1 st will cover the month of July). Program dues to be paid in either CASH, MONEY
ORDER, OR CASHIERS CHECK ONLY. Dues arrearage can/will result in discharge and/or other puniutive measures. If a resident departs
early for any reason any program fees paid will be forfeited. NO REFUNDS WILL BE ISSUED. If resident is
discharged any paid dues are forfeited.

Text field Late fees. Program dues for upcoming week is due by Sunday each week if paid weekly, or on
the 1 st of the month by 7:00pm if paying monthly. If program dues are not received by this specified
time a $25 late fee will be charged for that week. If residents are two weeks or more behind they will
be subject to discharge.

Text field Invoices – It is residents responsibility to know how much their programs dues are and have
them paid on time for period ahead. I understand this and agree that if I fail to do so I WILL be subject
to late fees and/or discharge. All residents are required to provide an email address that all financial
communication will be done through and are responsible to access and check this email.

Text field There is a $25/month supply fund fee that will be due the 1st of each month that will be used for
purchasing household supplies like toilet paper, cleaning supplies, etc

Text field I understand that management is here to help me follow a program of recovery and to provide a
safe, structured living environment. I understand that being confronted on my behaviors is part of living
in this house

Text field I understand that nothing in the house, except my own personal belongings, belongs to me and I
will not remove, damage, alter, or destroy anything in the house. This includes any furniture, appliances, fixtures, supplies, or anything in the house at all. I UNDERSTAND THAT IF I DO SO I WILL BE HELD CRIMINALLY LIABLE.

Text field No furniture or large appliances are to be brought without prior approval from Hazelbrook Sober
Living. Furniture or appliances may be donated to Hazelbrook Sober Living but must first be approved.

Text field Residents are not allowed to associate with residents that have been kicked out of Hazelbrook Sber
Living or left on bad terms or that are currently using

Text field Hazelbrook Sober Living retains the right to modify, delete, or add Program Rules at any time.
Residents will be informed of any such changes to the Program Rules. If Resident is unwilling to comply
with any new or changed Program Rule, Resident will be terminated from the Program.

Text field I understand that Hazelbrook Sober Living has the right to terminate me from the Program at any
time if it is in the best interest of the house and the other residents.

Text field This Agreement shall not be subject to debate. Its interpretation is solely at the discretion of
management.

Text field I agree that if I default on any portion of this contract and Hazelbrook Sober Living has to go to any
court to collect program fees, I am liable in full for the payment of these fees.

Text field I hereby release and hold harmless Hazelbrook Sober Living and its owners, from any and all
lawsuits that may be brought by me, any member of my family and heirs in perpetuity for any tort or
action whatever.

Text field I have read all the material on this application, and answered each question honestly. I have a
sincere desire to participate in the Hazelbrook Sober Living Program and live a clean and sober life. Any
questions I may have had were answered to my satisfaction.

Text field ADDITIONAL PROVISIONS

Paragraph

Date: Date
Resident Print Name:Client first name Client last name
Resident’s Signature:

Signature
Hazelbrook Management Signature:

Signature

 

Finanical Restriction Policy

 

Paying program dues is part of Hazelbrook Sober Living Program that was agreed upon and understood upon intake. As a participant of the program, and adult, it is YOUR RESPONSIBILTY to pay your program dues on time and in full. If you are recieving assitance it is YOUR RESPONSIBILTY to make sure that is happening and that it it communicated to Hazelbrook and necessary correspondence and confirmation is sent. It is not Hazelbrook's responsibilty to ask you to pay you rent or call to find out about your rent. Due to amount of people not follwing this Hazelbrook is implementing Financial Restriction Policy. Residents that are not current on program dues will be placed on "Financial Restriction". This means residents will be on Level 0 meaning they will have 8 pm curfew, no overnights or guests, plus will be required to complete 1 hour/day of supervised volunteer work at house (on top of regular) and are required to particapate in weekly Financial Wellness group. If you do not do this, and/or fail to get current you will be discharged. If you get more then 2 weeks behins you will be given notice to comply and you will be discharged from Hazelbrook.

Please sign to indicate you have read and understand this]

Signature

 

Hazelbrook Confidentiality Agreement

As a resident of Hazelbrook Sober Living I understand that anonymity and confidentiality is of utmost importance. Hazelbrook is a place where people need to feel safe to work on themselves without being worried.

I agree and am obligated to maintain anonymity and confidentiality at all times
while at Hazelbrook Sober Living and also after my stay at Hazelbrook Sober Living
and if I fail to do so I can/will be subject to legal actions taken against me.


“Anonymity and Confidentiality” includes, but is not limited to:
(initial next to each point to indicate that you have read and understand)


Text field I will not discuss business of any other resident that is currently or has been
at Hazelbrook Sober Living with anyone that is not currently in the Hazelbrook
Sober Living program this includes online or on social media

Text field I will not discuss anything pertaining to or about Hazelbrook Sober Living with
anyone that is not currently in the Hazelbrook Sober Living program

Text field I will not associate with neighbors about nature of Hazelbrook Sober Living,
its residents, or any details pertaining to Hazelbrook Sober Living. Keep all
association with neighbors to absolute minimum and keep very low profile in
neighborhood.

Text field I will not discuss personal or house business in detail at 12-Step or other
recovery events, this includes residents or staff of other sober living homes or
treatment centers or outpatient programs

Text field I agree to and understand Hazelbrook Sober Living’s Anonymity and
Confidentiality Policy and agree to respect privacy of Hazelbrook Sober Living and
its residents at all times. Any questions I have regarding this have been answered
and if any arise I will get them answered by Hazelbrook Staff prior to anything. I
understand that if I violate this policy I will be subject to termination from
program and potential legal action taken against me.

Print Name: Client first name Client last name
Signature: 

Signature

Date: Date

 

Resident Release

The following terms and agreement are to be read, fully understood, and initialed by the undersigned
resident of the Hazelbrook Sober Living Program.


Text field The undersigned resident agrees to release, waive, and discharge Hazelbrook Sober Living, LLC from
all liability for any and all loss or damage to participant on account of injury to the participant or
participant’s personal property, even injury or relapse resulting in the death of the participant in any of
the activities provided or occurring in the dwellings owned, operated, leased, managed, or affiliated
with Hazelbrook Sober Living, LLC.

Text field The undersigned resident releases Hazelbrook Sober Living, LLC from any claim whatsoever on
account of first aid, or medical treatment or service rendered to the participant as a result of injuries.

Text field Resident agrees to be financially liable and responsible for any and all medical costs related to any
injuries occurring while participating in Hazelbrook Sober Living, LLC or while living at any Hazelbrook
Sober Living property, whether owned, operated, leased, or managed by Hazelbrook Sober Living, LLC.

Text field The undersigned resident understands that they shall live in the facility under the agreed upon
contractual terms and rules as provided and explained, and Hazelbrook Sober Living may terminate their
residence at any time.

Text field Hazelbrook Sober Living, LLC is providing a sober living facility only and does not provide any
counseling, nor restrict the undersigned from making their own personal choices as long as they do not
violate facility rules as outlined in their contract for residence.

Text field Hazelbrook Sober Living, LLC will provide a housing facility in normal condition, and shall not be
held liable by the undersigned for any injury or loss to the tenant, or their belongings. The undersigned,
by and through their signature, acknowledges that they are responsible for any injury or accident and
will forever hold harmless Hazelbrook Sober Living, LLC.

Text field The undersigned understands that Hazelbrook Sober Living, LLC carries only insurance to cover the
dwelling and business assets located in the dwelling.

Text field The undersigned will immediately notify Hazelbrook Sober Living, LLC, in writing, of any incident
resulting in injury or loss. This will include a full accounting of the incident details.

Date Date
Resident Print Name:Client first name Client last name
Resident Signature:

Signature
Witness: Text field

 

Medication List

ALL MEDICATIONS MUST BE KEPT IN A SECURED LOCKBOX AT ALL TIMES 

Please list all medications being taken. Any medications found that are not listed or being used in way
other than prescribed will be considered contraband and treated as a relapse. Hazelbrook Sober Living
staff must be notified of any changes or additions in medications being taken prior to making changes to ensure it is allowed.

Narcotic medications are not allowed which means any kind of opiate, amphetamine, or benzo

Text fieldInitial here to indicate you understand and will comply with this

 

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

Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at

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

Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at

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

Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at

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

Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at

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

Pill count: Medication 5 pill count Discontinued at: Medication 5 discontinued at

Notes: Medication 5 notes

Medication #6

Medication: Medication 6 name Dosage: Medication 6 dosage

Quantity: Medication 6 quantity Category: Medication 6 category

Frequency: Medication 6 frequency MD: Medication 6 md

Pill count: Medication 6 pill count Discontinued at: Medication 6 discontinued at

Notes: Medication 6 notes

Medication #7

Medication: Medication 7 name Dosage: Medication 7 dosage

Quantity: Medication 7 quantity Category: Medication 7 category

Frequency: Medication 7 frequency MD: Medication 7 md

Pill count: Medication 7 pill count Discontinued at: Medication 7 discontinued at

Notes: Medication 7 notes

Medication #8

Medication: Medication 8 name Dosage: Medication 8 dosage

Quantity: Medication 8 quantity Category: Medication 8 category

Frequency: Medication 8 frequency MD: Medication 8 md

Pill count: Medication 8 pill count Discontinued at: Medication 8 discontinued at

Notes: Medication 8 notes

Medication #9

Medication: Medication 9 name Dosage: Medication 9 dosage

Quantity: Medication 9 quantity Category: Medication 9 category

Frequency: Medication 9 frequency MD: Medication 9 md

Pill count: Medication 9 pill count Discontinued at: Medication 9 discontinued at

Notes: Medication 9 notes

Medication #10

Medication: Medication 10 name Dosage: Medication 10 dosage

Quantity: Medication 10 quantity Category: Medication 10 category

Frequency: Medication 10 frequency MD: Medication 10 md

Pill count: Medication 10 pill count Discontinued at: Medication 10 discontinued at

Notes: Medication 10 notes

 

By signing you are acknowledging and certifying that the above information is accurate and that you
understand Hazelbrook Sober Living medication policy.
Resident Signature:

Signature

 

 

 

Hazelbrook Sober Living Program -  Client Handbook 2020

(Please read carefully, initial where indicated, and sign at bottom)

Program Description

Hazelbrook Sober Living Colorado is not just a place to live but a place where you will be a part of a family and grow as an individual. When you come to Hazelbrook you will be treated with love and respect. We are here to provide you with safe sober place to live, love and support, and structure to succeed. 

Our goal is lasting sobriety, which we know comes only from a complete change in lifestyle and spiritual growth. Drug or alcohol addiction usually has been going on for many years and it takes a little while for your mind to re-adapt to a normal life. We urge residents to stay with us for at least 90 days but they are welcome to stay as long as they want.

While at Hazelbrook Sober Living all residents are required to stay sober, work a recovery program, work, pay their program dues, and participate in the Hazelbrook recovery community. We require all residents to maintain complete abstinence from drugs and alcohol and submit to nightly BA's and random UA's to provide accountability and to make sure everyone in house in staying sober. If at anytime a resident fails or refuses a UA/BA they will be immediately discharged. All residents are required to actively work a recovery program of their choosing such as a 12-Step program or something similar, which includes attending recovery meetings, working with a sponsor, etc. We understand there are different avenues for recovery so we give residents the options to choose the recovery program that works best for them. All residents can expect to be held accountable and are required to keep track of meeting attendance. All residents are required to attend a weekly house meeting which counts towards meeting requirement, where residents go over how they have been doing that week and address any house issues.

Hazelbrook Recovery Goals

While at Hazelbrook Sober Living residents are required and encouraged to actively work towards, but not limited to, the following
Recovery Goals:

·       Learn to maintain complete abstinence from all mind-altering substances

·       Develop positive lifestyle habits

·       Work a program of recovery such as 12-step or similar which will promote spiritual growth  by attending meetings

·       Be a positive part of Hazelbrook Recovery community and develop positive and pro-social relationships with others in program and in recovery

·       Obtain employment and becoming self-supporting

·       Work to identify any mental or physical health issues that may be a barrier to recovery

·       Leave to live based on spiritual principles

·       Leave Hazelbrook better than when you entered!

 

Services Provided

Sober Living Services - Hazelbrook Sober Living is sober living program where Residents are provided with a safe, sober, and structured living environment where they have opportunity and are required to maintain complete abstinence from drugs and alcohol and work recovery program. This includes being overseen by live in house manager, sobriety monitoring, chore and curfew requirements, as well as peer support and in house recovery/house meetings and other recovery based activities.

Peer Recovery Coaching – Hazelbrook Sober Living has several Certified Peer Recovery Specialists that are available to provide such services to those that are interested and qualify. Peer recovery coaches walk side by side with individuals seeking recovery from substance use disorders. They help people to create their own recovery plans, and develop their own recovery pathways. Recovery coaches provide many different types of support, including emotional, job seeking skills, finding meetings and a sponsor, etc. While at Hazelbrook qualified residents have access to and OPTION to utilize Peer Recovery Coaches that specialize and are trained in guiding and helping people set up their recovery plans and can provide much needed support. 
 
Residents Rights

While at Hazelbrook Sober Living all residents have the right

·       to be treated with respect, fairness, and in non-discriminatory manner pursuant to “Hazelbrook Non-discriminatory Policy”.

·       to have a safe and sober environment that is free of drugs, alcohol, or violence.

·       to work on their sobriety in a safe and non-judgmental environment.

·       to have their information kept private.

·       to have concerns heard pursuant to Hazelbrook Grievance Policy.

·       to not be in program or participate in any required Hazelbrook activities

 

Financial Obligations

2020 Hazelbrook Program fees are:
$195.00 weekly OR $730.00 monthly. (Dues must be paid IN FULL on 1st of month in order to receive rate of $730/month.)  
There is a one time non-refundable intake fee of $150. (If resident moves in without paying intake fee or is voucher they are still liable for intake fee and have one month to pay)
There is a $25/month supply fee that cover essential house hold supplies due at beginning of each month

Late fees - $25 late fee will be assessed if program dues are not paid on time/period. Ex: every week that payment is late a $25/late fee will be assessed.

Program dues are to be paid for upcoming week/month (i.e., dues paid on July 1st will cover the month of July). Dues arrearage can/will result in discharge. If a resident departs early for any reason any program fees paid will be forfeited. NO REFUNDS WILL BE ISSUED FOR ANY REASON. If resident is discharged any paid dues are forfeited.

Text fieldInitial here to indicate that you read and fully understand and agree to Hazelbrook Financial Obligations

 

Levels

Hazelbrook Sober Living uses a levels system in which residents gain more freedoms and privledges as they progress through program by meeting Recovery Goals

 

When residents first arrive we want to make sure they establish good habits. Upon arrival all residents are on Level One.

Level One requirements:

·        10pm curfew 

·        5 recovery meetings per week

·        No overnights

·        Only immediate family guests

 

When residents have demonstrated that they have established good habits by showing that they have been working a recovery program, are current on rent, have a job, have completed UA intake, and have a sponsor then they can go to Level Two.  

 

Level Two requirements:

·        11pm weekdays/1am weekends curfew

·        3 recovery meetings per week

·        1 Overnight/week (pre-approved)

 

Level Three requirements:

Will be discussed at time, Level Three residents are expected to take on a leader and mentor role in program.

 

Level ZERO:

Level zero is a punative level. 

8pm curfew

Daily meetings

Only can go to work or recovery related events

 

In order to progress through Levels you must meet requirements and have been approved by Senior Resident. Also resident can and will be regressed levels if nt meeting requirements.

Text field Inintial to inicate that you have read and understand levels system and what is required to progress

 

Program Rules

 You are in a Sober Living Program/Environment. Your success and continuance in this program/environment is dependent upon your consistent good behavior and cooperation. Disruptive and/or Discourteous behavior will not be tolerated. Any contact with Illegal Drugs and/or Alcohol and/or violation of any of the following Rules & Guidelines can/will result in eviction. Your initials and signature indicate your understanding and agreement. When in doubt…ASK!

Please initial each:

Text fieldConsumption or possession of beverage alcohol in any form is strictly prohibited.

Text fieldUse or possession of all drugs in any form is strictly prohibited (this includes marijuana).

Text field Use and/or possession of drugs and/or alcohol will result in immediate eviction. If evicted for drugs and/or alcohol the resident agrees to leave the premises immediately and not return for any reason whatsoever, without permission from Hazelbrook Sober Living.

Text fieldLying, Cheating & Stealing are strictly prohibited. If caught, you will be evicted.

Text fieldResidents are required to submit to a Drug and Alcohol Screen/Test at any time (24/7) it is requested. A refusal and/or failure to provide an adequate sample will be treated the same as a positive test result. Any attempt to Cheat/Circumvent test will result in eviction.

Text fieldWhile at Hazelbrook Sober Living residents agree not to eat POPPYSEEDS or anything else that can cause positive UA, this will not be an acceptable excuse for hot positive UA

Text fieldResidents are required to actively be working a recovery program; the minimum daily attendance requirement is (5) per week if on level one and (3) per week if on level 2. Church or other faith group attendance can count as substitute for 12 step meetings.

Text fieldResidents are required to maintain a Home Group.

Text fieldResidents are required to maintain a working relationship with a Sponsor (or similar type of recovery mentor). It is recommended that each Resident be on track to take all “12 Steps” within 6 – 9 months from date of arrival at Hazelbrook Sober Living.

Text fieldResidents are required to maintain employment or be in school and have a verifiable and legitimate source of income.

Text fieldBehavior considered to be a “Conflict of Interest” (i.e., Sponsorship, Employment, Dating, etc.) between Residents is strictly prohibited.

Text fieldSmoking inside any Hazelbrook Sober Living home is strictly prohibited.

Text fieldHazelbrook Sober Living is NOT (at any time) responsible for a resident’s personal item’s/belonging(s). Residents are responsible for the security and safekeeping of their own personal item’s/belongings and are to pack and carry their item’s/belongings when they depart. If for any reason this does not occur, the Resident may contact the House Manager or Hazelbrook Sober Living regarding the retrieval/disposition of their personal item’s/belongings. Hazelbrook Sober Living will not store personal belongings for more than 2 weeks. If resident fails to pick up or arrange for pick-up of their belongings within 2 weeks of leaving they will automatically become donated.

Text fieldDisruptive/Discourteous behavior will not be tolerated and can/will result in eviction.

Text fieldGuests of the opposite sex are only allowed in common areas.

Text fieldOvernight guests are strictly prohibited.

Text fieldGuests are not permitted at the house beyond curfew and are only permitted in the common areas.

Text fieldGuests cannot be under the influence or in possession of drugs and/or alcohol.

Text fieldAll medication must be kept in secured lock box at all times

Text fieldResidents must adhere to appropriate curfew depending on which level they are on.

Text fieldHouse quiet time is 10:00pm to 7:00am. Any activity (i.e., Lights, TV, Telephone conversations, etc.) that disturb another residents ability to sleep/rest is prohibited..

Text fieldEvicted Residents are required to leave the premises immediately and not return under any circumstances.

Text fieldResidents of Hazelbrook Sober Living are discouraged from maintaining relationships with those evicted from the Hazelbrook Sober Living program.

Text fieldHouse Business Meetings are held weekly at date/time determined by House Manager/ Hazelbrook Sober Living and are mandatory for every client. An unexcused absence from any House Meeting can/will result in a fine, or eviction.

Text fieldOvernight/Weekend Passes are to be submitted to the House Manager a minimum of (3)days in advance. Authorization will be granted at the discretion of House Manager and Hazelbrook Sober Living.

Text fieldResidents are not permitted in any bedroom other than their own without permission from the resident(s) residing in that room; they must also be accompanied by the permitting resident.

Text field Thermostat is to be adjusted by the House Manager only.

Text field Washer & Dryer -- Be courteous. Clean dryer lint screen before and after every use and do not leave clothes unattended in the washer/dryer.

Text fieldChores are required to be completed daily. The House Manager is responsible for chore assignment and completion. Failure to complete assigned chore can/will result in eviction.

Text field A good General Clean-up of all areas inside & outside the home is required at all times.

Text fieldBeds are required to be made upon awakening. Respective areas are to be kept neat, clean and picked up at all times. NO SLOBS!

Text fieldTelephone — Every resident’s confidentiality is to be protected and respected! DO NOT TELL ANYONE THAT CALLS IF ANY RESIDENT DOES OR DOES NOT LIVE THERE. Simply say I can take a message for you and that’s it. Be courteous and pass along messages.

Text fieldTurn off lights, TV’s, Radio’s, Fans, etc., when not in use. Exterior doors are required to be locked when entering/exiting; no exceptions!

Text fieldResidents are required—at all times—to wear appropriate dress in common areas.

Text fieldSleeping in common areas is prohibited.

Text fieldKitchen—Appliances, Counter-tops, Utensils, Dishes, Pots, Pans, etc. will be cleaned and returned to their respective place (immediately) after each use.

Text fieldRefrigerator—Mark food/leftovers with Name/Date when initially placed in the refrigerator. Don’t eat other people’s food

Text fieldHazelbrook Sober Living residents are not permitted on any other property within the community without permission from the owner of the property. Additionally, the Hazelbrook Sober Living resident must be accompanied by the property owner.

Text fieldBe Accountable/Responsible and Communicate! Accountability, Communication eliminates need for excuses with House Manager

Text fieldA violation of any one of the aforementioned Rules & Guidelines can/will result in punitive measures and/or discharge from the Hazelbrook Sober Living Program.

 

Sexual Harrassment Policy

No form or sexual harassment or sexual misconduct is permitted at Hazelbrook Sober Living, this includes but is not limited to:

·        Inappropriate touching, joking, teasing, of any kind between residents, volunteers, or staff of Hazelbrook Sober Living

·        Dating between residents, volunteers, or staff of Hazelbrook Sober Living

·        Unwanted sexual advances

·        Quid pro quo or exchanges

If any kind of perceived violation of sexual harrassement policy is observed or reported this is to be immediately notified to Hazelbrook Sober Living owner in writing and to be handled.

 

Statement of Non-Discriminatory Practices

·        Hazelbrook Sober Living does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.

 

Medication Policy and Protocol

·        All medications are to be kept in a locked and secured location AT ALL TIMES (Vitamins are excluded). All residents must list any medications and count upon intake and medications are subject to med count at any time. Residents are not allowed to take any narcotic medication without express consent from Hazelbrook Staff.

·        M.A.T is allowed if prescribed and overseen by physician. Must be kept in secured location at all times if take home doses are given.

 

Resident Privacy Policy

·        The information that is collected from residents upon intake and while at Hazelbrook Sober Living is for the sole purpose of providing quality sober living service to Resident and will be kept private and confidential and will not be shared with any other residents or anyone outside of Hazelbrook Sober Living.

·        Hazelbrook Sober Living will not confirm nor deny if a Resident is at Hazelbrook Sober Living or has been in the program to anyone.

·        If a resident is sent by a partnering supervision agency such as Probation, Parole, etc. Hazelbrook Sober Living is obligated to share certain information such as intake, relapses, behavioral incidents, and discharges with agency staff.

 

Emergency/ Fire Escape Policy

·        In the event of a fire or other emergency, all residents should immediately evacuate premises to a safe area via one of several egress areas located through-out  house.

·        Call 911 immediately to report and also call Hazelbrook Owner, Alexandra Shvedov at 720-422-1742 or other Hazelbrook Staff if not able to reach.

·        Do not attempt to stay in house for any reason or attempt to put out fire, immediately evacuate!

·        If you are on 2nd floor and not able to exit through main level, use FIRE ESCAPE LADDER located on 2nd floor and use in one of egress windows to evacuate. If in basement evacuate through one of egress windows.

 

Overdose Policy

·        If you believe that a resident is suffering from an overdose, IMMEDIATELY CALL 911! Follow all instructions of 911

·        Do not panic, locate and administer Narcan which is located on each floor of each house

·        Call Hazelbrook Owner, Alexandra Shvedov at 720-422-1742 or other Hazelbrook Staff if not able to reach.

·        Stay close to resident to monitor and continue to speak to person to keep them awake. Do not attempt any “self-remedies” or administer any oanything except Narcan

Text fieldInitial to indicate that you read overdose policy

 

Discharge Policy

·        If a client is discharged from Hazelbrook they are not allowed on premises for any reason unless allowed and accompanied by Hazelbrook Staff.

·        If discharged client has belongings that have been left they may arrange time with Hazelbrook Staff to pick up. Belongings should not be touched by other residents but may be packed up by Senior Resident to make room for next resident. Belongings will be stored for a maximum of 2 weeks after which point they will be donated. (Before any belongings are donated this must be approved by Hazelbrook Management.)

Text field I understand that I am here as program participant and can be discharged at anytime for failure to comply with program requirements orif my presence is deemed distrurbing to program, without any eviction process. I have no tenant rights. I understand that if I am discharged from program and fail to leave when asked I will be trespassing and will held criminally charged. I further agree that I am liable for any costs associated with failure to comply with this. By initialing I indicate that I undersatnd and agree to this.

 

Drug Testing Policy

While at Hazelbrook Sober Living agree and understand they can be tested for Drugs and/or Alcohol at any time, for any reason, per agreement with Hazelbrook Sober Living. If they test positive, refuse compliance or attempt to cheat/circumvent the test in any way, they will be terminated from the Hazelbrook Sober Living program immediately and required to leave the premises within 30 minutes. In the event of this my emergency contacts will be notified and will not be able to return without being accompanied by Hazelbrook Sober Living management. (If allowed to return back to Hazelbrook Sober Living residents will be required to pay $150 intake fee again.)

Text field Sobriety monitoring is performed by 3rd Party; American Clinical Solutions/Continuum Recovery. All Hazelbrook Residents are required to complete Urine Analysis intake through Continuum Recovery in order to be able to receive full spectrum sobriety monitoring. This is to ensure highest quality of sobriety monitoring for all residents while and we are able to monitor levels if needed. If a residents chooses, and would like to have access to and receive additional services such as Peer Coaching, therapy, etc then they may complete full bio/psycho/social intake at Continuum Recovery, please ask your Senior Resident for details.

 

Grievance Procedure

All residents of Hazelbrook Sober Living should follow this process if any issue or grievance towards another member of program or Hazelbrook staff or the program occur. All Hazelbrook residents are entitled to file a grievance without fear of retaliation.

1.     Whenever possible grievances should be resolved informally between you and other party. If this does not lead to satisfactory solution please follow step # 2:

2.     You may put your complaint in writing stating any concerns of the matter and what you feel the fair solution should be and submit this to the Program Director.

3.     The Program Director will investigate the issue, gather facts from the incidence and involved parties and assist the resident in finding a satisfactory resolution within 10 days.

4.     If resident is not satisfied with resolution provided he/she has the right to appeal resolution based on information they feel is appropriate.

5.     Program Director will review appeal and either accept it for review, which will initiate new investigation/review process and offer different resolution, or Program Director will deny appeal and confirm resolution offered.

Formal grievance forms can be obtained from either house manager or any Hazelbrook Staff member.

 

Fine Policy

Text field Failure to comply with chore requirements will result in $5/day of chore not being done

*Fine money will go into house fund to be used by residents.

(These fines are subject to change and residents can be subject to eviction at anytime)

 

 

"Hazelbrook Recovery Plan"

Please fill out honestly and discuss with Senior Resident so we can best help you

 

Describe your history with substance use and the problems it has caused you in your life...

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What does “Recovery” mean to you?

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What are 3 Recovery Goals that you want to accomplish?

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What are some ways that Hazelbrook can support you during your stay that would be most beneficial to your recovery goals?

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What are, in your opinion, the biggest issues in your life that you are struggling with currently?

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What do you hope to get out of your stay at Hazelbrook?

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What are your 3 biggest “triggers” and why?

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What is your plan to meet your financial obligations for your time at Hazelbrook?

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We are here to help you in the best way we can! Please know that we are here for you and want to see you succeed and you can come to us with issues as they come up and for support. The more you express your needs and struggles the better we can assist you in your recovery!

 

 

Client first name Client last name have read, understand and agree to all parts of this Agreement and Hazelbrook Resident Handbook. All questions have been explained to me, and have discussd my Recovery Plan with Senior Resident.

 

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Please have Senior Resident review and sign....

 

I, Senior Resident, have reviewed this agreement to verify:

Text fieldproper facilty

Text fieldvalid email address and phone number

Text fieldhave recieved payment or signed off on WAGEES Funding Form

Text fieldhave reviewed and discussed Hazelbrook Recovery Plan

Text fieldhave looked over questions regarding COVID19 and if there was any "yes" answers I have instructed resident they cannot move in until providing negative COVID19 test results

 

 

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