FARR Florida Association of Recovery Residences Ceritified Residence NARR National Alliance for Recovery Residences
Atlantic Beach House Application
Applicant Information
Today’s date: Date Anticipated move-in date:Date
Legal Name: Client first name Client middle name Client last name
Name you would like to be called: Client first name
Date of birth: Date Phone Number: Client phone Email: Client email
Emergency contact name: Contact
Relapse contact name: Contact
Recovery and Substance Use
Sobriety Date: Date
Substance(s) of choice: Client substances of choice
Which of the following substances have you used in the past 6 months? Please check all that apply
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What usually leads you to use substances:
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Previous periods of sobriety: Text field
Longest period of sobriety: Text field
Support group/12 step participation: Text field
Home group: Text field
Sponsor: Text field
Are you willing to participate in a support group/12-step program while living in this house? Checkboxes
What are your recovery goals at this time: Paragraph
Are you currently in detox or substance use treatment? If so, where, and what is your intended length of stay?
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Medical
Health Insurance: Insurances
Current prescription medication:
Medication
Allergies or medical conditions (including mental health diagnoses):
Client allergies
Client diagnosis
If you are taking Medication Assisted Treatment prescriptions (Vivitrol, Suboxone,
Subutex): Text field
Why were you put on the medication initially?
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How long have you been on the medication?
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What is the dosage and directions?
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What is your healthcare provider’s plan for tapering you off the medication?
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Do you have any physical needs/accomodations that we should know about? If yes, please explain accomodations needed.
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Legal
Have you been arrested in the last 30 days? Checkboxes
If yes, please describe: Paragraph
Are you currently on probation or parole? Checkboxes
If yes, please describe: Paragraph
If yes, probation officer name: Text field phone number: Text field
Do you have any active restraining orders against you or someone else? Text field
Are you a convicted sex offender? Checkboxes
Employment
Are you currently employed? Text fieldIf yes, current employer: Text field
Address: Text field
Position: Text field
When was the last time you held a job? Specify what position and length of time employed:
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Current work schedule:
Monday Text field
Tuesday Text field
Wednesday Text field
Thursday Text field
Friday Text field
Saturday Text field
Sunday Text field
Are you willing and able to work full/part time? If no, please explain:
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If unemployed, what financial support do you have in order to pay rent weekly:
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I understand I am to attain employment within 2 weeks from move-in date or else I will
be asked to leave the residence. Please Initial Here Initials Text field
Please list vocational skill/certifications:
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Are you receiving welfare or other non job-related income: Checkboxes
If yes, please explain:Paragraph
Do you have a valid ID: Checkboxes
Do you have a valid driver’s license: Checkboxes
Do you have a car: Checkboxes
If yes, please provide car make and model Text field
Do you have a valid Social Security card? Checkboxes
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Other Info
Please list hobbies and special interests:
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What would you say your best characteristics are:
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Have you ever lived in a home shared with other people:
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Do you anticipate any problems with living in a shared space:
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Atlantic Beach House Recovery Residence
House Rules
I agree to comply with the following conditions:
1. No-tolerance policy: Residents must not use alcohol including over-the-counter
items such as mouthwash with alcohol, vanilla extract, or illegal
drugs/mood-altering substances or medications including but not limited to
inhalants, diet pills, sleeping pills, sleeping aids, medical marijuana, or other
medications not prescribed to me by my physician.
2. Drug screens: Residents will submit to a minimum once monthly random drug
and alcohol screening. Failure to test negative will result in immediate expulsion from the
residence. Residents must attend a 3-day detox and pass a drug screen in order
to be considered for reentry into the house. Should a resident be suspected
under the influence of substances/alcohol, a drug screen may be requested at
any time.
3. Medication: No medication can be left out in rooms. All meds must be stored in
your individual medication lock box. You are responsible for your medication and
no sharing with other residents is permitted. You must provide a copy of your
prescription medication to the house manager upon entry to the house.
4. Rent: Payment is due at the time of admission to the house. A one-time
administrative fee of $100.00 is due at time of intake in addition to the rent.
Residents will pay rent of $200.00 per week on time, due Sunday by 5PM. Rent
can be paid in the form of debit/credit card, cashier’s check, money order, cash, Zelle or Venmo.
This covers water, electric, gas, internet, and a weekly family meal.
I understand that I forfeit full amount of rent should I vacate the
residence anytime after 24 hours from admission. A late fee of $10.00 will be
collected for any late rent payments.
5. Length of Stay: All housing contracts are in effect on a weekly basis from
Sunday-Sunday. It is the responsibility of the resident to inform the House
Manager of their intended move-out date so we can help you plan for a
successful transition.
6. Community: Residents must attend the weekly house meetings on Sundays at
9AM. Any issues or concerns should be addressed during the meeting.
7. Curfew: All residents within their first 30 days will have a 9pm curfew. After 30 days, residents will abide by a house curfew of 11PM Monday-Thursday and
12AM Friday-Sunday. Residents are expected to check in with house manager by curfew every night.
8. House locks: Upon entering the Atlantic Beach House, residents will be given a
4-digit lock code that gives you access to the kitchen door. Doors will be locked
at curfew each night.
9. Overnights: No overnight stays for the first 30 days of living at the recovery
house. Permission for overnight stays must be approved by the house manager
Mike or Brenna. Residents are allowed 2 overnight passes per month. I
understand that upon my return from the overnight, I will be asked to take a
drug/alcohol test which costs $10. Maintained sobriety, accordance with house
rules, up to date rent payment, and good behavior will be required for approval of
any overnights. See overnight request form for details.
10. Guests: No guests allowed at the house (inside or outside) at any point. Should
you receive transportation from someone else, they are permitted to wait in the
driveway for no more than 5 minutes.
11. Employment: Residents must obtain employment, attend school, attend
outpatient therapy, or participate in volunteer work. Please communicate with the
senior resident/house manager if you have an atypical employment schedule.
We will work with you!
12. Living Spaces: Residents must keep personal and communal living spaces
clean and orderly. No food or drink other than water is permitted in the bedrooms.
House Manager has permission to hold accountable any resident not following
this rule.
13. Chores: Residents will be assigned a weekly chore at the house meeting.
Residents are expected to maintain this chore for the duration of each week.
Chore assignments can be found on the family dry erase board.
14. Parking/cars: Residents with cars assume responsibility for the safety of their
vehicles and belongings inside their vehicles. Residents are not required to drive
any other residents if they do not feel comfortable. Give rides at your own
discretion. You are permitted to park anywhere in the driveway or the grass
bordering the road.
15. Laundry: Use of the laundry room is permitted from 8AM-11PM. Laundry
detergent is provided once monthly. Residents are responsible for providing
additional laundry detergent.
16. Behavior: Residents must be respectful to all housing managers/senior
residents. Residents will be respectful to all property including but not limited to
interior and exterior furniture, gym equipment, television, laundry equipment,
appliances, and vehicles. Should a resident violate the behavior expectations of
the house, they will be asked to vacate.
17. Exercise equipment: Residents are permitted to use the exercise equipment
from 5AM-11PM. Residents are responsible for their safety and the Atlantic
Beach House is not responsible should an injury occur using this equipment.
Residents exercise at their own risk.
18. Vacating the house: Should a resident be asked to vacate the house, the senior
resident/house manager will escort the resident to collect their belongings and
vacate. Residents have 1 hour from the time they are asked to vacate to collect
their belongings from their room. If belongings are left after 1 hour, they will be
held for 10 days in the garage, at which point they will be donated if they are not
picked up.
I understand that my adherence to these conditions will be evaluated ongoing by the
Senior Resident and House Managers, and will be the basis for my continued stay and
participation in the Beach House Recovery Residence.
Resident Signature Signature Date Date
Housing Manager Signature Date Date
Witness Signature Date Date