Beacon Support Homes Application
General Info
First Name: Client first name
Last Name:Client last name
Date of Birth: Client birthdate
Most Recent Address: Client Address
Phone Number: Client phone
Referral Source: Client Referred By
If other, explain: Text field
Email: Client email
Allergies: Client allergies
Ethnicity: Client ethnicity
Recovery
Drug of Choice: Client substances of choice
Sober Date: RecoveryHistory
Recovery Program: Text field
Describe your progress in Recovery so far: Paragraph
Employment & Vehicle
Employment Status: EmploymentHistory
Employer Name: Text field
Drivers License #: Text field
Vehicle information: Text field
Emergency Contacts
Emergency Contact: Contact
Legal History
Legal Details
Probation: Probation
Parole: Radio buttons
Officer Name: Text field
Officer Phone: Text field
Location: Text field
Completion Date: Text field
Court Dates: Text field
Status: Text field
Open Cases: Text field
Criminal History: Client Number
Sex Offender: Radio buttons
Sex Offense Details: Paragraph
House Rules
Break these rules and your stay will be terminated
You have 3 warnings ONLY
(RED TYPE = IMMEDIATE REMOVAL FROM HOME)
1) SAFETY:
a) No loitering or hanging out in the front yard for any reason. The back patio is used for this.
b) Keep entry and exit doors closed and locked at all times
c) No weapons, drugs, or paraphernalia of any kind
d) Do not leave items on the floor that may cause a slipping or trip hazard
e) If you spill anything on the floor immediately wipe it up and the place a wet floor sign
f) In case of an emergency, we need all residents to sign in and out of the home when leaving the property.
2) GENERAL:
a) Do not steal or use another person’s items without permission.
b) Do not open or enter any cabinets or closets with locks
c) Turn lights off when not in use
d) You may NOT enter another resident's room at any time
e) Keep room door closed at all times
f) Clothes must be worn outside of your room.
g) Never leave personal items unattended in common areas of the home
h) Kitchen closes at 8pm
i) Residents can enter the home during these hours ONLY:
6AM-11PM Sunday – Thursday, 12am TV off
6AM – 12AM Friday and Saturday, 12am TV off
24 hour prior written notice must be given for any & all exception
j) If you are diabetic or need to give yourself shots using a syringe, you will need to have a medical grade bin
to dispose of used needles properly.
3) SMOKING, ALCOHOL, AND DRUGS:
a) Smoking on backyard patio ONLY
b) No Alcohol consumption or storage of alcohol in or around premises
c) Do not share medication
d) No storage or use of illegal drugs or unprescribed medication allowed
e) Residents are required to submit to a drug and alcohol test at any time as per request. 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 a
test will result in a dismissal.
4) CLEANLINESS:
a) The house MUST be cleaned thoroughly in an orderly fashion every day before bedtime
b) Chores are to be completed DAILY
c) Put trash in the trash can and nowhere else
d) Clean and put away dirty dishes immediately after use
e) Clean up immediately after you use the bathroom
f) Your room shall be kept in an orderly and sanitary condition at ALL times
g) Food is only to be consumed in the kitchen & dining room; Food is NOT ALLOWED in bedrooms at any
time.
h) If you spill anything or make a mess anywhere in the house, including your room, YOU will be responsible
for
Submitted on July 31, 2025, 8:41 PM
cleaning it up.
5) YOUR ROOM:
a) Make your bed DAILY in the morning
b) You may NOT enter another resident's room at any time
c) Mattress covers must NEVER be removed
d) Keep room door closed at all times (No Personal Locks )
e) Keep personal items inside of your room (Valuable items should be secured)
f) Personal items should be stored or in drawers. Nothing should be visible on top of dressers.
g) All rooms are subject to search by Beacon Support Homes staff and Case Managers
h) NO Food or Drinks in the rooms at any time.
6) PERSONAL HYGIENE
a) Diapers, bed pads, or any personal hygiene items must be disposed of properly.
b) You shall keep up with your personal hygiene by bathing and brushing your teeth frequently.
c) You shall have no complaints that you or your personal space has offensive odors.
7) BEHAVIOR:
a) No aggressive or violent behavior EVER!
b) No profanity or offensive language directed at any residents, neighbors, or Beacon Support Homes staff or
helpers
c) No lending or borrowing money, cars or other property from other residents or neighbor
d) All residents must attend outpatient treatment
e) No romantic advances on Beacon Support Homes staff
8) LAUNDRY:
a) Use of Laundry on scheduled day and time ONLY
b) Laundry area must be clean
c) You may not wash another person’s clothes
d) You may not put feces soiled items into any washer or dryer in the home
9) PERSONAL BELONGINGS:
a) NO Personal Televisions, Refrigerators, Air Conditioners or TV/Movie Projectors in the rooms.
b) No more than 2 suitcases worth of belongings can be moved in. This is transitional housing, not a permanent
home. Additional personal belongings should be stored elsewhere (storage unit, with family, etc). A good rule
of thumb is no more than 10 outfits for adults. For children, no more than 20 outfits.
My signature signifies, I have read and understand what I can and cannot do while living in Anchor House. I
understand and agree that if I break any rules within this document in red type, my stay will be terminated
immediately, and I will be banned from living in other homes that Beacon Support Homes manages.
Signature
License Agreement
LICENSE AGREEMENT
Instructions:
Certify that you agree to the below items by clicking the check box.
I understand that THIS AGREEMENT IS NOT A LEASE. Initials Text field
I understand that Beacon Support Homes provides and pays for Utilities, furnishings, cleaning services and controls all keys to the premises and individual rooms Initials Text field
I understand and agree to pay the Monthly Bed fee of $1,100 per month. Due 1-4th of the month. Initials Text field
I understand and agree to pay $400 non-refundable administration fee. Due at move in. Initials Text field
I understand and agree that if the monthly bed fee is paid after the 4th of the month, a late fee of $50 per day will be assessed. Initials Text field
I understand that if I violate any rules of the licensee agreement, I may be considered a criminal trespasser and subject to arrest under State Penal Code, “Criminal Trespass” Initials Text field
I understand that Beacon Support Homes has broad authority to lien all property contained within the licensee’s room Initials Text field
I have read and understand the house rules provided to me (see addendum VIII) Initials Text field
I understand that Beacon Support Homes is NOT an assisted living facility or a nursing home and that
LANDLORD & PROPERTY MANAGER DO NOT provide assistance with activities of daily living, medicine
management, bathing, brushing, shaving, cutting food, toileting, transportation, supervision outside of the
residence, incontinence care, dressing, movement or other daily activities. Outsourced 3rd parties may stop by
and provide these services to the “licensee” if the “licensee” has a relationship with this outsourced 3rd party,
however under no circumstances does Beacon Support Homes provide these services directly. Initials Text field
I understand that any damages (other than normal wear) will be my financial responsibility Initials Text field
I understand that Beacon Support Homes will have a lien for unpaid fees against all of Licensee's nonexempt
personal property that is in the Property and may seize such nonexempt property if Licensee fails to pay rent.
Property Code governs the rights and obligations of the parties regarding Landlord's lien. Landlord may collect
a charge for packing, removing, or storing property seized in addition to any other amounts Landlord is entitled
to receive. Landlord may sell or dispose of any seized property in accordance with the provisions of the Property
Code. Initials Text field
Any person who is a prevailing party in any legal proceeding brought under or related to the transaction described
in this license agreement is entitled to recover a maximum of $500 attorney’s fees from the non-prevailing party. Initials Text field
Pests, Responsibility, and Property
PEST CONTROL AND INFESTATION
Bed bug addendum and other infestation:
A. This addendum addresses situations related to bed bugs and other infestations (roaches, gnats etc.) which
may be discovered infesting the dwelling or personal property in the dwelling. You (licensee) understand that
we relied on your representations to us in this addendum.
B. INSPECTION. You agree that you:
Have inspected the dwelling prior to move-in and that you did not observe any evidence of bed bugs, roaches or
other infestation
C. INFESTATIONS. Prior to move-in, Licensee is certifying that they have examined the property for bed bugs,
rodents and other bug infestations and did not observe any evidence of bed bugs or bed bug infestation or any
other infestations including roaches, gnats etc. Therefore, in signing this addendum, Licensee certifies that if
bed bugs or other bug infestations are later found in this unit, they will be deemed to have been introduced by
the Licensee or one of the Licensee’s guests and that the LICENSEE WILL BE RESPONSIBLE FOR THE
PEST TREATMENT, including all reasonable costs of cleaning and pest control treatments. If we must move
other residents in order to treat adjoining or neighboring dwellings to your dwelling unit, you will be liable for
payment of any lost rental income and other expenses incurred by us to relocate the residents. If you fail to pay
us for any costs you are liable for, you will be in default, and we will have the right to terminate your right of
occupancy and exercise all rights and remedies under the lease contract. You will be held directly liable and will
deal directly with city officials including but not limited to section 8 inspectors, code compliance inspectors, law
enforcement officers and any other party that deems the unit unclean and infested and will hold Beacon Support
Homes harmless for bed bug, roach or other pest infestations.
D. COOPERATION. If we confirm the presence or infestation of bed bugs or other bugs or rodents, you
must cooperate and coordinate with us and our pest control agents AT YOUR EXPENSE. You must follow all
directions from us or our agents to clean and treat the dwelling that is infested. You must remove or destroy
personal property that cannot be treated or cleaned as close as possible to the time the dwelling is treated. We
have the right to require you to temporarily vacate the dwelling and remove all furniture, clothing and personal
belongings in order for us to perform pest control AT YOUR EXPENSE. If you fail to cooperate with us, you
will be in default and we will have the right to terminate your right of occupancy and exercise all rights and
remedies under the lease contract. YOU ALSO AGREE TO ALLOW US TO EXTERMINATE THESE PESTS
IMMEDIATELY UPON DETERMINATION THAT INFESTATION HAS OCURRED AND THAT YOU WILL
REIMBURSE US FOR THIS EXTERMINATION.
Initial in the box to left to certify the above paragraphs regarding pest control and infestation
Signature
RESPONSIBILITIES OF LICENSEE, LICENSEE’S REPRESENTATIVE AND/OR LEGAL REPRESENTATIVE
A. You, your representative and/or legal representative, to the extent specified in this agreement, are
responsible for the following:
1. Payment of the monthly fees
2. Supply of personal clothing, activities of daily living, medicine, medicine management and other
normal day-to-day items and tasks including but not limited to doctor visits, transportation, case management
and social worker appointment meetings and scheduling’s.
Initial in the box to left to certify the above paragraphs regarding responsibilities of licensee, licensee's
representative and/or legal representative
Signature
PROPERTY MAINTENANCE
A. Licensee’s General Responsibilities: Licensee, at Licensee’s expense, must:
(1) Keep the Property clean and sanitary;(2) Promptly dispose of all garbage in appropriate receptacles;(3) Take
action to promptly eliminate any dangerous condition on the Property and/or room;(4) Certify that they will
perform all activities of daily living without the help or assistance of any Beacon Support Homes
representative such as showering, taking medications, shaving, cutting and preparing food, toileting, transportation, dressing and any other activity performed on a daily basis.(5) Certify that they have inspected their room
and that the room is clean and well-maintained.(6) Adhere to fire safety protocols
Initial in the box to left to certify the above paragraphs regarding Property Maintanence
Signature
Indemnification
INDEMNIFICATION
Instructions:
Certify that you agree to the below items by clicking the check box.
I agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given a
reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my
own legal counsel review this Agreement if I so desire. Initials Text field
Each party hereby agrees to indemnify the other and the other’s employees, officers, directors, agents, family
members and other related parties against all damages for bodily injury, including death, or damage to real or
tangible personal property to the extent proximately caused in the course of performing this Agreement. Initials Text field
It is my intention and I understand that I am binding myself, my heirs, agents, relatives, executors, administrators,
assigns and successors in interest, and understanding this, so hereby expressly release and discharge Beacon
Support Homes, its agents, owners, landlords, directors, executives, successors, administrators, assigns, affiliates
and agents from any claims against Beacon Support Homes created or arising out of, or in any way whatsoever
related to the service or housing space provided. I hereby waive any claim for damages to persons or property,
which may occur as the result of the use of the said premises. This waiver includes any negligent acts or omissions
caused directly or in-directly by Beacon Support Homes or the owners of said Property, including its officers,
directors, or employees and understand that my claims, which may in the future arise out of personal injuries,
accident, death, hurricanes, tornadoes, rain, fire or other acts of God to the residence, myself or damage to my
property of any kind, are hereby waived. Initials Text field
I, and any and all family, relatives, attorneys, assignees and any others acting on my behalf hereby further agree
to indemnify and hold harmless Beacon Support Homes, its owners, representatives, agents or Owners of said
Property, including its officers, directors, or employees, from any claims or damages, which may occur to the
undersigned licensee or to any child, invitee, or guest of the undersigned. Initials Text field
It is understood and agreed that this agreement includes, but is not limited to, injuries occurring due to:
slipping and falling on any surfaces wet or dry, transportation to and from the premises or any other location,
fires, sprained or broken limbs, cuts, abrasions, eye injuries, bacterial infections, death, fights, riots, stabbings,
tornados, hurricanes, floods, hail storms, acts of terrorism and any other acts of God, accidents or injuries on the
property or off the property. Initials Text field
Licensee assumes all risk of harm resulting from the use of any pools, trampolines, or recreational facilities
on Beacon Support Homes property and waives all claims against the Beacon Support Homes arising from or
relating to the use of said facilities or the participation in such activities and programs by Licensee and his or her
guests, even if caused by the Beacon Support Homes’s negligence or gross negligence. The use of said facilities
shall be at the sole risk of Licensee and his or her guests.” Initials Text field
Each party agrees to indemnify and hold harmless the other party and its employees, members, land-lord,
successors, attorneys, family members, agents and assigns, from any claims, liabilities, losses, damages, and
expenses asserted against the other party and arising out of the indemnifying party’s negligence, willful
misconduct, and negligent performance of, or failure to perform, any of its duties or obligations under this
Agreement. The provisions of this indemnification are solely for the benefit of the parties hereto and not intended
to create or grant any rights, contractual or otherwise, to another person or entity. Initials Text field
Licensee will indemnify and hold harmless Beacon Support Homes, its agents, owners, staff, directors and
officers against all liability, including liability arising from death or injury to person or property during the term
of this agreement, and any renewal or extension thereof, caused by any act or omission of the Licensee, or the
family, guests, agents or employees of the Licensee. b) Licensee will indemnify and save Beacon Support Homes
harmless from all liability, damage or expense incurred by Beacon Support Homes as a result of death or injury
to persons or damage to property (including the Premises) where this License Agreement required the Licensee
to procure insurance for said liability, damage or expense and Licensee failed to do so. Initials Text field
Beacon Support Homes, its agents, owners, staff, directors and officers shall not be liable for any damage or
loss to person or property caused by other licensees or other persons, or caused by theft, vandalism, fire, water,
smoke, explosions or other causes unless the same arises solely from the omission, fault, negligence or other
misconduct of Beacon Support Homes. Failure or delay in enforcing license covenants of other Licensees shall
not be deemed to be negligence, omission, fault or other misconduct. Initials Text field
Licensee acknowledges that security cameras are used at our facilities to ensure the security of the premises from
theft, unauthorized access, or damage to the property. All security cameras record both video and audio, and
are strategically positioned so as to not interfere with the peaceful possession of our residents or their privacy.
Licensee accepts the monitoring of interior living spaces and exterior spaces by security camera, and agrees not
to tamper with the security cameras. Initials Text field
The licensee expressly acknowledges and agrees that this license agreement does not create a landlord-tenant
relationship and that the licensee does not have any of the rights afforded to tenants under California law,
including but not limited to rights under the unlawful detainer statutes. The licensee waives any right to contest
removal from the premises under any claim of unlawful detainer or other tenant protections. The licensee agrees
that, upon termination of this license, they will immediately vacate the premises, and failure to do so may result
in immediate removal as a trespasser, subject to arrest and other legal actions. Initials Text field
Any disputes arising out of or related to this Agreement shall be resolved through binding arbitration in
accordance with the rules of the American Arbitration Association. The venue for arbitration shall be Solano
County, California, unless both parties mutually agree to an alternative location. If either party demonstrates
that the designated venue would impose a substantial hardship, the parties agree to confer in good faith to select
an alternative, mutually agreeable venue or to conduct the arbitration remotely. Initials Text field
Rules
RULES
Instructions:
Certify that you agree to the below items by clicking the check box.
I am aware that the move-in fee is non-refundable under any and all circumstances Initials Text field
I am aware that I may be fined and or discharged from the property for violation of house rules/destruction of
property Initials Text field
My payment (in full) is due by no later than the fifth of each month via a third party representative payee or credit
card, or agreed upon app. Initials Text field
I am required to notify the House Leader or House Manager a minimum of thirty days prior to vacating the
premises or I will be charged the full fee for the current term Initials Text field
I understand that upon leaving an Beacon Support Homes location by my will or as a result from rule infractions Initials Text field
I will not be eligible for a refund. Initials Text field
I understand that this agreement is not a lease. License holder may give a minimum of 30 day notice to vacate.
Any damages by licensee will be the financial responsibility of the licensee. Management of Beacon Support
Homes may terminate this licensee agreement at any time. Violation of house rules may result in fines or my
dismissal from the property. Threats or acts of physical violence against other licensees or management will
result in immediate termination of this license and may result in filing of criminal charges. Beacon Support
Homes reserves the right to terminate this agreement immediately and without prior notice in the event of any
violation of the house rules, use or possession of prohibited substances, or other behaviors deemed detrimental
to the community or property. Upon termination, the licensee must vacate the premises immediately. Initials Text field
I understand that “vacating” the premises is defined as ALL of my belongings and myself leaving the property Initials Text field
I understand that some of the food used is sourced from the community (for example, local food banks). Licensees
are expected to participate in these resources. Initials Text field
Beacon Support Homes reserves the right to temporarily or permanently relocate the licensee to another facility
owned or operated by Beacon Support Homes if deemed necessary for maintenance, safety, or operational
reasons. Any costs associated with such relocation will be the sole responsibility of the licensee. Initials Text field
Management / Staff of Beacon Support Homes may ask me to provide a urine sample or breathalyzer when:
• Erratic or other behavior typical of a person under the influence of alcohol or illegal drugs is observed
• Erratic or other behavior typical of a person under the influence of alcohol or illegal drugs is observed
• Randomly
Initials Text field
Under no circumstances are drugs, alcohol or other “non-prescribed” medication allowed in the property. I
understand that if I have been found to be using or in possession of any of the above items, I will immediately be
in violation of this agreement and will be asked to vacate the unit immediately. Sharing of any type of medication
with others is also prohibited and grounds for immediate dismissal. Initials Text field
Beacon Support Homes, its agents, and authorized personnel reserve the right to enter the licensed premises,
including any rooms or common areas occupied by the licensee, at any time and without prior notice for the
purposes of conducting regular inspections, ensuring compliance with house rules, performing maintenance,
conducting safety checks, or responding to emergencies. The licensee agrees to cooperate with these inspections
and understands that failure to do so may result in the termination of this license agreement. Initials Text field
Agreement Authorization
I, the undersigned, have read this License Agreement and agree to abide by the terms and conditions.
I, the undersigned, understand that by signing below, I agree to all of the check boxes contained in the pages of
this web form.
I, the undersigned, that all of my applicant information contained in this web form is true and accurate.
Full Legal Name: Text field
Signature: Signature