JOMO House, Inc
4655 Bluegrass Ave
Boise, ID 83703
(house location)
JOMO House is a male sober working environment that provides stabilization and a supportive
sober atmosphere.
The general criteria for acceptance into JOMO House are:
1. Residents must be sober and actively maintaining sobriety by being involved in a recovery
program.
2. Residents must have the ability to pay $148.75 dollars rent weekly. A $112.50 dollar non-
refundable entry fee is required to reserve a bed. This entry fee is applied toward rent, and is
required to enter the house. IF A RESIDENT IS
ASKED TO LEAVE, THERE ARE NO REFUNDS. If leaving is voluntary, you must give a
one-week notice. During this one-week period payment of rent is not required since all
residents have a one-week reserve that will be used to pay their rent.
3. Residents must have a willingness to cooperate with other residents and contribute to
improving the house and community.
Type or Print (clearly) All Information. Use additional sheet if necessary. Please read application
CAREFULLY.
I hereby apply for membership into JOMO House, and I am providing the following information for
use by JOMO House in determining my eligibility and appropriateness for residency.
Answer all questions that apply.
Name: Client first name Client last name
Previous Home Address: Client Address
City: Client City State: Client State Zip: Client Zip
Email: Client email Cell Number: Client phone
Work:Text field Home: Text field
Gender: Client gender Birthdate: Client birthdate
Social Security No.: Text field
Are you currently homeless/without a permanent place to live?
Radio buttons
Marital Status: Client marital status
Health Insurance:
Provider: Client insurance provider Insurance Plan: Client insurance plan
Group ID: Client insurance group ID Policy#: Client insurance policy #
Therapist: Text field
Psychiatrist: Text field
Physician: Text field
Medical Condition:
Paragraph
Diagnosis: Client diagnosis
Health problems: Client health problems
Are you taking any prescription medications?
Radio buttons
Benzodiazepines?
Radio buttons
(Anyone taking Suboxone must submit an approval letter from a Doctor or clinic.)
If yes, please list them:
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
Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at
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
Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at
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
Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at
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
Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at
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
Pill count: Medication 5 pill count Discontinued at: Medication 5 discontinued at
Notes: Medication 5 notes
Drug of choice:
Client substances of choice
Have you been to rehab?
Radio buttons
If Yes, where?
Treatment Center #1
Name: Treatment center 1 name
Address: Treatment center 1 address
City: Treatment center 1 city State: Treatment center 1 state Zip: Treatment center 1 zip
Admitted: Treatment center 1 started Discharged: Treatment center 1 ended
Notes: Treatment center 1 notes
Type: Treatment center 1 type
Reason for discharge: Treatment center 1 reason for discharge
Treatment Center #2
Name: Treatment center 2 name
Address: Treatment center 2 address
City: Treatment center 2 city State: Treatment center 2 state Zip: Treatment center 2 zip
Admitted: Treatment center 2 started Discharged: Treatment center 2 ended
Notes: Treatment center 2 notes
Type: Treatment center 2 type
Reason for discharge: Treatment center 2 reason for discharge
Treatment Center #3
Name: Treatment center 3 name
Address: Treatment center 3 city
City: Treatment center 3 state State: Treatment center 3 state Zip: Treatment center 3 zip
Admitted: Treatment center 3 started Discharged: Treatment center 3 ended
Notes: Treatment center 3 notes
Type: Treatment center 3 type
Reason for discharge: Treatment center 3 reason for discharge
Treatment Center #4
Name: Treatment center 4 name
Address: Treatment center 3 address
City: Treatment center 3 state State: Treatment center 3 state Zip: Treatment center 3 zip
Admitted: Treatment center 4 started Discharged: Treatment center 4 ended
Notes: Treatment center 4 notes
Type: Treatment center 4 type
Reason for discharge: Treatment center 4 reason for discharge
Treatment Center #5
Name: Treatment center 5 name
Address: Treatment center 5 address
City: Treatment center 5 city State: Treatment center 5 state Zip: Treatment center 5 zip
Admitted: Treatment center 5 started Discharged: Treatment center 5 ended
Notes: Treatment center 5 notes
Type: Treatment center 5 type
Reason for discharge: Treatment center 5 reason for discharge
Are you a recovering:
Checkboxes
Your sobriety/recovery date: Client sobriety date
Do you attend AA or N/A meetings?
Radio buttons
Employer: Employer 1 name Position: Employment 1 position
Do you have any outstanding warrants?
Radio buttons
Do you have any sex offenses?
Radio buttons
Referred by(If coming from an institution, which one?): : Client referred by
Referral source (Referral source must be filled in, whether an institution or NOT.): Client referral source
Release/Discharge Date: Date
List name of parole or probation officer: Text field
List names and telephone numbers of two individuals who may be contacted in the event of an
emergency:
Contact #1
Name: Contact 1 name Phone: Contact 1 phone
Type: Contact 1 type Email: Contact 1 email
Contact #2
Name: Contact 2 name Phone: Contact 2 phone
Type: Contact 2 type Email: Contact 2 email
JOMO House is a sober environment and will not tolerate residents using alcohol/drugs. If a
resident is found to be using either substance he will be immediately discharged.
Signature:
Signature
Date: Date
Consent Form
I, an applicant for JOMO House do hereby voluntarily consent to requests for urines and/or saliva
specimen and agree to fully participate in the testing program.
If my specimen is found to be positive, I understand I will be immediately discharged from JOMO
House.
Signature:
Signature
Date: Date
I, Client first name Client last name , have read the aforementioned consent information,
rules, criteria and application provided by JOMO House and I understand that if I am accepted I
agree to the following terms:
I waive any landlord/tenant rights with respect to residency at JOMO House. I understand and
agree to comply with the rules and responsibility of the house.
In addition, I understand there will not be any money refunded if I am required to leave. If leaving
is voluntary, I must give a one-week notice.
Signature:
Signature
Date: Date