Application + House Rules (Lead Form - Other)

Resident Application 

 

Resident Information 

Full Name: Client first nameClient last name

Social Security Number: SSN

Driver License Number: Text field

If you do not have a valid driver's license, list what form of ID you currently have: Text field

Phone Number in Treatment: Text field

Cell Phone Number: Client phone

Email Address: Client email

DOB: Client birthdate Sobriety Date: Text field

Give a brief statement why you are seeking Sober Living: 

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Have you resided in sober living in the past: Radio buttons

If yes, when, where, and for how long: 

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Do you have a significant other: Radio buttons

If yes, answer the questions below. If no, write N/A or leave them blank. 

Name of significant other: Text field

Relationship: Text field How Long: Text field

Does your significant other use drugs or alcohol, even socially: Radio buttons

If yes, what and how often: Text field

Is your significant other supportive of your recovery and supportive of your willingness to enroll in the program at The Opal house: Radio buttons

Are you willing to sign a release of information for your significant other: Radio buttons

If no, give your reasons why: 

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Do you have any children: Radio buttons

If yes, please list their first names and ages only: 

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Who is caring for your children while you are in sober living: Text field

Are you involved in the court system regarding your children or involved with DCF: Radio buttons

If yes, please describe: 

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Emergency Contacts

Contact

Please answer all questions below, if not applicable write N/A. 

Are you currently enrolled in a treatment program: Radio buttons

If so, list the name of the facility and the house of the program: 

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Have you completed treatment recently: Radio buttons

If so, where, what type, and length of stay: Text field

Did you successfully complete treatment: Radio buttons

If no, please explain in detail why: 

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Are you willing to sign a release of information for that facility: Radio buttons

If no, state your reason why: 

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Do you currently have a sponsor: Radio buttons

Sponsor's first name & phone number: Text field

Are you wiling to sign a release of information for your sponsor: Radio buttons

Do you have a NA, AA, or OA network: Radio buttons

If so, how many women do you have in your network: Text field

Are you willing to attend weekly meetings and engage in 12-step recovery: Radio buttons

Do you have transporation: Radio buttons

Year, Make, and Model of Vehicle: Text field

Tag Number: Text field

Employment History 

List current, and previous employer

EmploymentHistory

Do you have any medical issues that would interfere with working or volunteering full time: Radio buttons

If yes, please explain in detail: 

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Do you have any physical limitations? Are you able to care for yourself AKA showering, walking, cooking, cleaning, etc: Radio buttons

If you have physical limitations please describe: 

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Medical Information

Are you currently taking any medications: Radio buttons

If yes, please list in the space below:

Medication

Have you ever been diagnosed with any mental health issues:Radio buttons

If yes, what are the diagnoses and are your symptoms currently manageable: 

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Have you ever attempted suicide: Radio buttons

If yes, please describe below including dates: 

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Have you ever been Baker Acted to a psychicatric facility: Radio buttons

If so, when and describe: 

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Do you currently engage in any type of self-harm or self-mutilation: Radio buttons

If so, describe and include the date of the last time you harmed yourself: 

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Are you willing to sign a no harm contract if permitted into the program: Radio buttons

Do you currently have a physician who manages your medications: Radio buttons

If yes, list the name of your physician, phone number and the date of your next follow up appointment. If no, referrals will be given to you. 

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Eating Disorders

Have you ever been diagnosed with an eating disorder or nutritional problem: Radio buttons

If yes, please describe: 

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Are you currently binging, purging, or restricting your food: Radio buttons

Do you have a meal/food plan you follow on a daily basis: Radio buttons

If yes, describe: Text field

Do you see a nutritionist or dietitian: Radio buttons

If yes, please provide their name, phone number, and date of your last/next appointment: 

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Are you willing to submit to random drug testing: Radio buttons

Are you willing to breathalyze daily: Radio buttons

Legal Issues 

Do you have any current pending legal issues: Radio buttons

If yes, describe in detail below, including any upcoming court dates: 

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Do you have a history of arrests: Radio buttons

If so, list the year and charges below: 

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Length of Stay

What is your anticipated length of stay at The Opal House: Text field

Are you willing to commit to a minimum of 6 months at The Opal House: Radio buttons

If no, please describe why: 

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What is your anticipated admission date: Client admit date

Fees

  Admin Fee Deposit 1st Week's Rent Total due upon Move In
Opal House 1 $150 $185 $185 $520
Opal House 2 $150 $195 $195 $540
Opal House 3 $150 $210 $210 $570

$150.00 Admin Fee includes: interview, intake, and drug testing. Non-Refundable Deposit is fully refundable after 6 month commitment is met. 

I understand in the event I be dismissed from the program for any reason including relapse I understand that any deposit or pre-paid fees will be forfeited. Text field

I understand if I do not complete my 6 month commitment to the Opal House I understand taht any deposit or pre-paid fees will be forfeited. Text field

All information disclosed is completely confidential. A phone assessment or intake appointment will be scheduled prior to admission to the Opal House. If you have any further questions please call us at 813.474.9309 or you can visit or our website at opalrecoveryhome.com

Signature of Applicant: Signature

Printed Name: Text field

CRRA Signature: Signature

 

House Rules and Regulations 

Your intials next to each statement acknowledge that you have reviewed, will abide by, and have received a copy of the house rules and regulations of The Opal House. Breaking of any of the below rules and regulations are grounds for immediate discharge from the program. 

Text field 1. Must attend a minimum four 12-Step meetings per week. Meeting list to be turned into staff every Wednesday. If not enrolled in a treatment program you must attend one 12-Step meeting daily for the first 90 days. 

Text field 2. Must have a sponsor within the first 7 days of admission. Report the name of your sponsor to Administrator. Must be willing to sign a release of information for your sponsor if requested.

Text field 3. Attend mandatory House Meeting held each week. Be on time. No expections. Failure to attend a house meeting could be grounds for discharge from the Opal House Program. 

 Text field 4. Abide by the curfew, which is 10:00 PM on weekdays and 11:00 PM on weekends for the first 30 days. After the first 30 days, the curfew is 11:00 PM on weekdays and 12:00 AM on the weekends. Any exceptions must be approved by staff one week prior. No expections. 

Text field 5. You must be employed, attending school, or volunteering for a minimum of 25 hours per week within two weeks of admission. Enrollment in an outpatient or day treatment program may be substituted for employment in some cases. 

Text field 6. Job search forms must be turned into Administrator at weekly House Meeting. No employment in bars, clubs, or any other environment deemed unsafe by Administrator. Must get approval prior to starting new employment. 

Text field 7. If enrolled in an outpatient/day treatment program you must adhere to all treatment guidelines. Being staff discharged from the treatment program could result in termination of your contract with the Opal House. 

Text field 8. Submit to random drug screening/breathalyzer immediately upon request. There are no expections and failure to do so can result in immediate termination of your contract with the Opal House. 

Text field 9. No persons other than residents allowed inside the Opal House unless staff member is present or prior visitation request is approved. Approved visitors are only allowed on outside patio and/or common living area #1. 

Text field 10. No males permitted on property unless approved by staff. 

Text field 11. All visitors must sign in and out when entering or leaving the property. Failure to do so can result in a loss of visitation privileges. 

Text field 12. All chores will be completed daily, as assigned. 

Text field 13. No entering others living areas without permission and th person being present. 

Text field 14. No eating/borrowing food that does not belong to you. Label all food with your name on it as well as expiration date. 

Text field 15. No giving out door codes or lending of garage key. No duplicating of keys. If you forget your door code or lose a garage key report it immediately to Administrator. 

Text field 16. House is to be locked and all doors secured prior to leaving. 

Text field 17. Abide by laundry schedule at all times. NO chlorine bleach allowed. Color-safe bleach only. No cleaning products containing bleach are permitted. 

Text field 18. No borrowing of money, cigarettes, clothing, or personal items. If you are in need, see administrator. 

Text field 19. No nail polish or hair dyes allowed outside of bathroom area. Resident is responsible for any damage caused by such items. 

Text field 20. The Opal House phone number is to be given out only to sponsor network or immediate family members. 

Text field 21. No use of alcohol or any mood- or mind-altering substances. The Opal House has a Zero Tolerance Policy. If relapse occurs, you acknowledge that you could be discharged from the program immediately. 

Text field 22. If you have an eating disorder, you must follow your food plan at all times. Not following or adhereing to your meal plan will be considered a relapse. 

Text field 23. Should I be dismised from the program for any reason, including relapse, I understand any deposit or fees will be forfeited. 

Signature: Signature

Printed Name: Text field

 

CRRA Signature: Signature

Printed Name: Text field