Application for Admission
If you have any questions, please call 1-844-SOBR-DFW.
Program Details - please read through the following before completing the application:
At Living by Design Collective, LLC, our goal is to support your permanent recovery from drugs & alcohol. To achieve that goal, we ensure a safe, structured environment where all residents have the opportunity to succeed.
Minimum Requirements for Admission to Living by Design Collective, LLC:
1. Commitment to your recovery. Minimum stays are not required. However, we ask that you commit to staying at least 4 months. You may stay longer. Your stay will be terminated without notice if house rules are not 100% complied with.
2. Complete abstinence from all mind & mood altering substances. This includes illegal drugs, alcohol, prescription drugs (certain medical exceptions can be made), or any other substance used to alter your mind or mood. We do drug & alcohol screening several times a month. We reserve the right not to accept residents taking certain prescription medications (i.e., Vyvanse, Suboxone, or Subutex; this list is not exhaustive), and we also screen for those.
3. You must have or be willing to obtain a "sponsor," a person who will personally accompany you through your recovery.
We expect everyone to have a sponsor within 1 week. One-on-one work with a sponsor is the most crucial part of your recovery, and you must meet with your sponsor once a week.
Upon move-in, a blackout period of 10 calendar days will start. During this period, no guests are allowed, and trips outside the home are only for sponsor meetings, doctor appointments, court appearances, or other staff—and court-approved activities.
4. Willingness to stay clean and sober. Active group participation, step-work with your sponsor, and attending outside 12-step meetings are mandatory.
5. Complete willingness to follow all rules and directions. Living by Design Collective, LLC is a structured living environment that allows all residents to live fully within structure and accountability.
6. You must either have a job or be actively seeking employment (this will be verified), attend an outpatient program, or attend school full time during the day (you may also have to work part time). Part of the structure of recovery is learning to fill our days with worthwhile and productive activities.
7. Willingness to focus on yourself. We have a strict “No Fraternization” policy with any other licensee sharing space together.
8. Willingness to attend all weekly mandatory house meetings. There may also be invitations to participate in other meetings, retreats, and functions throughout the year.
CLIENT INFORMATION
Client Name: Client first nameClient middle nameClient last name Birthdate: Client birthdate Today's Date:Date
Race:Client race Gender:Client gender Marital Status:Client marital status Veteran Status:Client veteran status
Address: Client Address City:Client City State:Client State Zipcode:Client Zip Social Security Number:SSN
Phone Number:Client phone Email: Client email Pronoun:Client pronoun Nickname:Client nickname
Name of Case Manager or Discharge Coordinator:Therapist/Clinician
Email of Case Manager or Discharge Coordinator:Text field
Phone Number of Case Manager or Discharge Coordinator:Text field
Name of Most Recent Treatment Center Attended:TreatmentCenterHistory
Start Date at Treatment Center: Text field
When do you anticipate completing this program? Text field
Drug(s) of Choice:Client substances of choice
MAT Used? Dropdown If yes, input the name of the medication. If MAT is not used, enter NA: Medication
Do you have a co-occurring diagnosis? Dropdown
If yes, enter the diagnosis here. If no, enter NA:Client diagnosis
Do you have medication for the diagnosis listed above? Dropdown If yes, input the name of the medication: Medication
How many days of medication do you have at the time of completing this application?Text field days
Have you lived in a sober living home before? Dropdown If yes, enter the name of the sober living home. If no, enter NA:SoberLivingHistory
Please list any convictions, legal charges pending, or probation status: Text field
Please list current employer: EmploymentHistory
Please list your source of income: Text field
Please list your funding source for your stay at Living by Design:Text field
Please list any food allergies or type 'none':Text field
FOOD ALLERGY DISCLOSURE AND WAIVER
Residents and guests are solely responsible for disclosing their food allergies, intolerances, and dietary restrictions to Living by Design Collective LLC ("the Facility"). The Facility makes reasonable efforts to accommodate disclosed dietary needs but cannot guarantee an allergen-free environment. By signing below, you acknowledge that you have fully disclosed all food allergies to the Facility, understand that cross-contamination may occur, and agree to assume all risks associated with food consumption on the premises or at any events, whether affiliated with the Facility or not. The Facility shall not be held liable for any allergic reactions resulting from failure to disclose allergies or inadvertent exposure to allergens.
Initials Text fieldIntials indicates review, understanding, and agreement with the food allergy disclosure and waiver written above.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
NOTICE AND TERMINATION POLICY
By submitting this application, I acknowledge and agree that a minimum of thirty (30) days’ written notice is required prior to terminating any future agreement with Living by Design Collective, LLC, for space within any of their sober living dwellings.If the required 30-day notice is not provided, a full 30-day fee will be immediately due and is non-refundable.
If an agency or third party is paying on behalf of their client, the agency or third party agrees to pay the full 30-day fee, even if the resident vacates the premises before the 30-day period has passed. This fee is non-refundable and will not be prorated.
AUTHORIZATION FOR SERVICES/LIABILITY AGREEMENT
I, Client first nameClient middle nameClient last name, do hereby voluntarily consent to residential services provided by Living by Design Collective, LLC. Failure to comply with house rules and/or participate in recommendations may result in the termination of any agreements. No information will be released outside of Living by Design Collective, LLC without express written consent. I give consent for the team to share information about me and my substance abuse or mental health records in order to support emergency treatment services required by third parties. I understand that I must provide truthful information regarding my medical and legal status. I understand the Living by Design Collective, LLC will not harbor fugitives from the legal system. I also agree that Living by Design Collective, LLC is not liable for any accidents, injuries, and/or death (overdoses, suicide) in or near any of its properties.
I hereby certify that I have read and fully understand the above agreement.
Signature
Client Signature
Today's Date:Date
AUTHORIZATION FOR RELEASE OF INFORMATION
Full Name of Client:Client first nameClient middle nameClient last name
Date of Birth:Client birthdate
I hereby request and authorize :
Living by Design Collective, LLC
5301 Alpha Road Ste #80, Office #343
Dallas, Texas 75240
Phone (844) SOBR-DFW
To disclose to or obtain from all providers and individuals except the following named persons or facilities:Text field
The following information from my records (if available):
-History and Physical exam
-Alcohol and Drug Abuse Treatment records
-TB (tuberculosis) Results
I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patients records, 41 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV related information
about me, STD related information about me, and TB related information about me is protected by State law and cannot be disclosed unless the disclosure is authorized by State law. I also understand that I may revoke this consent, in writing, at any time except to the extent that action has been taken in
reliance on it, and that in any event this consent automatically expires as follows. If you wish to discuss revoking this authorization or refuse to sign this form, you can ask for assistance from your therapist or Program Director who can go over this information in more detail:
Initials Text field (Initials here) The period necessary to complete all transactions on accounts related to services provided to me.
Signature
Client's Signature
Date
Today's Date