Resident Application 

Resident Information 

Full Name: 

Treatment Center: 

Social Security Number: 

Driver License Number: 

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

Phone Number in Treatment: 

Therapist Phone number in Treatment: 

Cell Phone Number: 

Email Address: 

DOB: 

Give a brief statement why you are seeking Sober Living: 

Have you resided in sober living in the past: 

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

Do you have a significant other: 

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

Name of significant other: 

Relationship:  How Long: 

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

If yes, what and how often: 

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

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

If no, give your reasons why: 

Do you have any children: 

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

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

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

If yes, please describe: 

Emergency Contacts

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

Are you currently enrolled in a treatment program: 

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

Have you completed treatment recently: 

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

Did you successfully complete treatment: 

If no, please explain in detail why: 

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

If no, state your reason why: 

Do you currently have a sponsor: 

Sponsor's first name & phone number: 

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

Do you have a NA, AA, or OA network: 

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

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

Do you have transporation: 

Year, Make, and Model of Vehicle: 

Tag Number: 

Employment History 

List current, and previous employer

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

If yes, please explain in detail: 

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

If you have physical limitations please describe: 

Medical Information

Are you currently taking any medications: 

If yes, please list in the space below:

Have you ever been diagnosed with any mental health issues:

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

Have you ever attempted suicide: 

If yes, please describe below including dates: 

Have you ever been Baker Acted to a psychicatric facility: 

If so, when and describe: 

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

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

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

Do you currently have a physician who manages your medications: 

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. 

Eating Disorders

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

If yes, please describe: 

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

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

If yes, describe: 

Do you see a nutritionist or dietitian: 

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

Are you willing to submit to random drug testing: 

Are you willing to breathalyze daily: 

Legal Issues 

Do you have any current pending legal issues: 

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

Do you have a history of arrests: 

If so, list the year and charges below: 

Length of Stay

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

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

If no, please describe why: 

What is your anticipated admission date: 

Fees

$125.00 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. 

I understand in the event that if I have been late more than three times paying rent all deposit and pre-paid fees will be forfeited. 

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

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: 

Printed Name: 

CRRA 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. 

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. 

 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.

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. 

  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. 

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. 

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. 

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. 

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. 

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. 

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

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. 

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

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

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

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. 

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

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

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

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

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

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. 

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. 

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

Signature: 

Printed Name: 

CRRA Signature: 

Printed Name: