Intake Forms



Name: Resident first name Resident last name

Cell Phone: Resident phone

Email Address: Resident email

Age: Text field

Date of Birth:Resident birthdate

Driver’s License No. and State: Text field

Parent’s names and phone numbers:

Name: Contact 1 name Phone: Contact 1 phone

Name: Contact 2 name Phone: Contact 2 phone

Emergency Contact Name, Address, and Phone:

Name:Contact 3 name

Address: Text field

Phone Number: Contact 3 phone

Financially Responsible Party: Text field

      Phone: Text field

      Email:  Text field

Date of move in: Resident move in date

Sobriety Date: Resident sobriety date

Drug of choice: Resident substance of choice

Are you discharging from a Treatment Facility:

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Name of Treatment Center: Treatment center 1 name

Length of Stay: Text field 

Did you successfully complete the Program:

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Date of discharge: Treatment center 1 ended

Name of contact person at the Treatment Center: Contact 4 name Contact 4 phone

Will you be attending an Outpatient Program: 

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Name of the Program:Text field

Days of the week attending and time: Paragraph

Will you be attending an Aftercare Meeting:

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Do you have a sponsor?

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Name and contact number: Contact 5 name Contact 5 phone

Do you have any Court Cases pending: Paragraph

List any medications that you will be taking while living at Higher Plane Recovery:

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

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

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

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

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

Notes: Medication 5 notes

Are you willing to commit to living at Higher Plane Recovery for a minimum period of 90 days?

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Resident Agreement and Rules



This Agreement is between Recovery Holdings LLC, Higher Plane Recovery and (Name of Resident) Client first name Client last name entered into on (Date) Date.  The term of the Agreement is for a minimum of 3 months which may be extended thereafter on a month to month basis.  It is required that the Resident provide a 14-day notice if they are planning to move out after they have completed the first 3 months or any additional subsequent months.  The Resident acknowledges that they have reviewed all of the rules and terms of this Agreement and agree to abide by those conditions. The Agreement may be terminated by Higher Plane Recovery for noncompliance at its sole discretion.


It is required that all Residents shall remain abstinent from any and all mind altering substances, including, but not limited to: Alcohol, Cocaine, Heroin, Methamphetamine, Marijuana, Hallucinogens, Opiates, Benzodiazepines, Amphetamines, Stimulants, and Synthetics (Spice, K2, Bath Salts, Kratom etc.)  

1. Any and all drug use on or off the property is strictly prohibited and will result in immediate dismissal of the resident from the premises.  

2. If any Resident is suspected of being under the influence, they will be immediately tested and their belongings are subject to search.

3. If a resident is found to be in possession of any type of restricted drugs or paraphernalia, whether on their person or in their belongings, they will be discharged immediately. 



All Residents shall be tested throughout the week on Thursday and Sunday, as well as random drug screenings at owners discretion. Residents may be asked to undergo and submit a toxicology screening at any time.  A positive result will subject the resident to immediate dismissal. Refusal to submit to a test will be treated as a positive test result. If Higher Plane Recovery has a reasonable suspicion that a resident is under the influence, a positive drug test is not required for dismissal. 



1.) All residents must be employed within TWO WEEKS of their arrival to Higher Plane Recovery. 

A. Starting on the resident’s fourth day in the house, he must be gone from the house between the hours of 10am to 3pm. Once employment is gained, this rule no longer applies.


2.) All residents must have a sponsor and be ACTIVELY working the steps within two weeks of their arrival to Higher Plane Recovery.


Higher Plane Recovery employs a phase system which is designed to give each Resident more flexibility as they progress in their recovery. While living at Loyola, residents will adhere to the Phase 1 guidelines. There are 3 phases.

Phase I - This is the entry level for Residents who are just beginning at Higher Plane Recovery. This is a minimum of 4-week period for residents at Marywood and a minimum of 12-week period for residents at Loyola. The primary responsibilities and objectives include:

1. A curfew of 10:00pm Sunday thru Thursday and 11:00pm Friday and Saturday.

2. Weekly attendance at 5 12-Step recovery meetings.

3. Obtaining a Sponsor, actively working the steps, and communicating with the Sponsor on a weekly basis.

4. Maintaining all medical, aftercare, or therapist appointments.

5. Gaining employment within the first two weeks. After the first two weeks, resident must perform at least 30 hours of weekly volunteer service until he is working at least 30+ hours at his place of employment or attending school or vocational program.

6. Resident is restricted to no passes during this period.

Phase II - After meeting all of the requirements of Phase I, a Resident may transition to the next phase. The primary responsibilities and objectives include:

1. A curfew extension to 11:00pm Sunday thru Thursday and 12:00am Friday and Saturday.

2. Eligibility for 2 over passes per month for a period not to exceed 1 night. Passes cannot be accrued or used on adjoining dates. 

3. Weekly attendance at 4 12-Step recovery meetings.

4. Continue to actively work the steps and meet with Sponsor.

5. Have a home group.

6. Have an H&I commitment.

7. Be employed for a minimum of 20+ hours per week or attending school or a vocational program.

Phase III - After meeting all of the requirements of Phase II, a Resident may transition to the final phase.  The primary responsibilities and objectives include:

1. Remain living in Higher Plane Recovery for a period exceeding 2 months.

2. A curfew extension to 12:00am Sunday thru Thursday and 1:00am Friday and Saturday.

3. Eligibility for 3 passes per month for a period, not to exceed 1 night per pass with consideration for longer passes based upon reasonable request. Passes cannot be accrued or used on adjoining dates. 

4. Weekly attendance at 3 12-Step recovery meetings.

5. Be employed for a minimum of 20+ hours or attend school full time (a minimum of 12 credit hours).

6. Continue to demonstrate responsibility at the sober house and in their recovery.

Residents must continue to maintain all commitments at the sober house, including following all house rules and regulations, performing their daily chores, and adhering to the house curfew in order to remain on a phase.  A failure to be consistent with the requirements may subject the Resident to being placed on a lower phase, suspension of passes, reductions in curfew, behavioral contracts, or dismissal.


There shall be a mandatory house meeting for ALL RESIDENTS, WITHOUT EXCEPTION every Sunday night at 7:00 pm. All Residents are to be prepared to talk about house issues, their lives, and their recovery.


1. Residents are permitted overnight passes on phase 2 or 3, providing they are in compliance with all house rules, finances, and expectations.

2. Residents must complete a Pass Request form and submit it to the House Manager a minimum of 3 days in advance.  

3. No passes may extend beyond 1 night.  Any exceptions, or special circumstances, must be approved.

4. Upon return from a Pass, the Resident will be tested for Drugs & Alcohol. 


1. Any drug or alcohol use on or off the premises.

2. Physical contact between Residents and/or their guests. 

3. Physical altercation or verbal threats.

4. Theft of any other Residents property including toiletries, food, or   beverages.

5. Weapons of any kind on the property.  

6. Disrespectful or aggressive behavior to any Resident of Staff member.  

7. No pets or animals are allowed on the property at any time. 

8. No participation or involvement in any illegal activity, including any new arrests or warrants.

9. Failure to return to the property by curfew without prior permission or compliance with the terms and conditions of a pass. 

10. Physical damage to Higher Plane Recovery property.

11. Repeated violations or failure to comply with the house rules.


No narcotic prescription medications are permitted. No exceptions.  All other prescribed medications must be registered with the house manager.  Any unauthorized use or abuse of prescription medication shall be grounds for immediate dismissal.   All prescriptions are to be stored in drawers and out of view of all others. 


Higher Plane makes every effort to provide a structured, comfortable, and superior living environment for all of its residents.  Any repairs or requests for needs of its Residents shall be considered immediately. In order to maintain a clean, neat, and presentable environment, each resident will be assigned weekly chores at the house meeting, in addition to maintaining his/her own bed and personal space.  Chores will be listed on a Board in the kitchen area at each house meeting. Upon completion of the chore, each Resident shall sign off that they have completed the chore and notify the House Manager or Chore Captain. If for any reason the House Manager finds that the chore is not completed, the Resident may be requested to redo the chore.

Additionally, each Resident is responsible for the following:

1. Resident bed is to be properly and neatly made every day by 10am. All clothes and personal items must be stored at all times in dressers and closets. No clothes are to be left on the floor or on beds.

2. All closet doors are to be closed.

3. All dresser drawers are to be closed.

4. No food or drinks (other than water) is allowed in the bedrooms.

5. All drink containers are to be disposed of after using.

6. All suitcases are to be stored in the closet.

7. No personal items are to be left out in the bathrooms. (Each Resident shall be provided a bin for toiletries).

8. All residents are required to clean up after themselves. 

9. When using the kitchen, all dishes, pots & pans must be cleaned immediately after every use.  No dishes should be left in the sink. Use your dish, wash your dish, load your dish.

10. Do not leave your personal items in the common areas. 

11. Residents must maintain good personal hygiene at all times.  

12. Turn off lights, televisions, and computers when not in use or when leaving the house.

Please respect all members of the community and the standards set by Higher Plane Recovery.  It is the desire and objective of Higher Plane Recovery to provide and insure a welcoming and organized way of life.


Resident Property:

Higher Plane Recovery is not responsible for resident’s property.  All resident property must be moved out of residence within 24 hours of moving out.  Higher Plane Recovery is not responsible for any property left at the residence.



Male visitors are only permitted on the property until 9:00pm Sunday thru Thursday and 10:00pm Friday and Saturday.  Female visitors are never permitted on the property unless it is immediate family and must be approved by the house manager. No Resident may have more than 1 guests at any time.  All guests must respect all house rules.

1. Visitors must stay in the public areas of the house at all times, and are prohibited from entering any bedroom at any time.

2. All visitation is at the discretion of the house manager.  

3. Any visitors who appear to be under the influence of any mind altering substances will be asked to leave immediately and may not return to the property.

4. Any visitor who is in the program and has just relapsed must have a minimum of 30 days sober and the permission of the House Manager before entering the property.

5. Visitors may not be left unattended while they are on property.  Any violation of these House Rules by a guest will be treated as a violation by the Resident.


Higher Plane Recovery is equipped with a large capacity washer and dryer for the convenience of its residents.  All laundry detergent and dryer sheets are also supplied. The machines are for the use of all residents and therefore Residents are requested not to leave their clothes in the machine after they are finished.  If you start laundry be available to complete it. Empty the lint trap when finished and check it before you begin a load. Do not leave your laundry or hamper in the laundry area.


Residents are allowed to have motor vehicles.  However, they must hold a valid driver’s license, registration, and current insurance.  All Residents must park in the driveway or on the street in front of the property, facing the right direction. A car that is not functioning or in use is not allowed at the property. Please respect the neighbors by not playing loud music outside or through the neighborhood. Violation of this will result in disciplinary action.


1. Doors must be closed when smoking outside.  

2. Smoking and vaping is permitted in the backyard.

3. All cigarette butts, and other trash, must be disposed of in the designated receptacles.

4. There is NO smoking or vaping in the front of the house.



All residents are required to attend two or more H&I opportunities per month throughout their entire length of stay here at Higher Plane Recovery. Each H&I must be verifiable with a person of contact and that person’s personal cell phone number. Failure to complete the weekly H&I requirement will result in loss of privileges, lowering of house phases, and eventually will result in being asked to leave Higher Plane Recovery.


1. If you are the last one to leave the property, please make sure the outside doors are secured.

2. Any contact by any person or persons requesting information on the property shall be referred to the House Manager immediately.

3. If a Resident has been discharged from Higher Plane Recovery, they are not permitted to enter the property for a minimum of 30 days and must have the approval of the House Manager. 


It is imperative that Residents shall have respect, and consideration for the surrounding neighbors.  Residents are not permitted to congregate or smoke in front of the house, make any nuisance, or loud behavior in front of, or on the property.  Park all vehicles in the driveway or on the proper side of the street in front of the property. There is no loitering in vehicles in the front of the property. Respect all speed restrictions on the street. Please walk on the driveway and not on the grass.


In the case of any emergency, the Residents are immediately required to call 911, and the House Manager.  


This is not a lease agreement.  Any Resident may be discharged, at any time, for non-compliance with the rules, regulations, or expectations of Higher Plane Recovery.  Residents will forfeit their deposit, and the remaining balance. The Resident understands and waives any recourse, or right, under any law that would apply to a tenant under a lease agreement.


Higher Plane Recovery may give progress reports to any of the following:  payer, treatment center, resident’s counselors.


1. The Resident gives their implied and express consent to Staff to implement all provisions and conditions of this Agreement.  

2. Higher Plane Recovery reserves the right to revise the listed policies above.

3. The Resident has read, reviewed, and understands all of the above. 

4. By signing below, Resident signifies his or her acceptance, without exception.  


PRINTED NAME OF RESIDENT:   Client first name Client last name



Date: Date

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DATE: Date