For Individuals Recovering Sound Thinking9 Bird St, Dorchester, MA 02125Stephenie Jackson, Owner 617-506-8861 business Tel. 617-407-7879 cell 857-271-3946 fax
Name: Client first name Client middle name Client last name Previous Address: Client Address City: Client City State: Client State Zip: Client ZipTelephone: Main phone: Client phone Work Text field Home: Text fieldDate of birth: Client birthdate Sex:Client gender Social Security No.Text fieldAre you currently homeless/without a permanent place to live?
Radio buttonsMarital Status: Client marital status
Health Insurance number:
Provider: Client insurance provider Insurance Plan: Client insurance plan
Group ID: Client insurance group ID Policy#: Client insurance policy #
Therapist: name: Contact 1 name Phone: Contact 1 phone
Psychiatrist:name: Contact 2 name Phone: Contact 2 phone
Physician:Name: Contact 3 name Phone: Contact 3 phone
Medical Condition:Client diagnosisAre you taking any prescription medications?
If yes, please list them:
Medication 1: 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 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 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 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
Drug of choice:Client substances of choice
Have you been to rehab?
If Yes, where?
Center name 1: 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
Center Name 2: 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
Date of last TB test: Date
Are you a recovering: Alcoholic? Checkboxes Drug addict?Checkboxes
Sobriety/Recovery date:Recovery history 1 sobriety date
Do you attend AA or N/A meetings?
mployer: Employer 1 name Position: Employment 1 position
Started: Employment 1 started Ended: Employment 1 ended
Income: Employment 1 income
Type: Employment 1 type
Notes: Employment 1 notes
Do you have any outstanding warrants?
Do you have any sex offenses?
Referral source: (If coming from an institution, which one?):
Client referral source
Release/Discharge Date: Text field
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:
Name: Contact 4 name Phone: Contact 4 phone
Type: Contact 4 type Email: Contact 4 email
Name: Contact 5 name Phone: Contact 5 phone
Type: Contact 5 type Email: Contact 5 email
F.I.R.S.T. Recovery Home is a sober environment and cannot tolerate program members using alcohol/drugs. If a member is foundto be using either substance he will be immediately discharged for illegal activity. It is understood by the FIRST members that useof alcohol or drugs is a violation of their membership because it is either unlawful or in violation of terms of their probation orothers released to this recovery home.
F.I.R.S.T. Recovery HomeFor Individuals Recovering Sound Thinking9 Bird St, Dorchester, MA 02125Stephenie Jackson, Owner 617-506-8861 business Tel. 617-407-7879 cell857-271-3946 fax
F.I.R.S.T. Recovery Home is a sober environment that provides stabilization and a supportive soberatmosphere.
1. Members must be sober and actively maintaining sobriety by being involved in a recoveryprogram.
2. Members must have the ability to pay $150.00 weekly rent.
3. A $250 security deposit is required
4. Residents of the community house must have a willingness to cooperate with other personsliving here and contribute to improving the house and community.
5. Members are expected to abstain from alcohol and other substances. If using alcohol/drugs orinvolved in any drug activity, member will be immediately placed in a detox. Upon completionof a seven day detox the resident can return to the house. In addition, every resident will bescreened a minimum of 1-2 times per week. If it is suspected a resident is not sober the housemay give a random drug screen.
6. Sexual contact between residents is cause for immediate discharge.
7. Non-payment of your rent is subject to disciplinary action and may result in discharge. Therent is due by Wednesday of each week prior to leaving the House for the weekend.
8. Disruptive, threatening or abusive behavior to any member and/or staff will not be toleratedand is grounds for discharge.
9. Members must agree to participate in at least one N/A or AA meetings per week.
10. Members must agree to participate in a minimum of (1) urine screen per weeek.
11. Members must attend one 1 in-house meeting upon request when necessary.
12. All residents living at F.I.R.S.T. must be in the house by: 11:00 pm. Sunday through Thursday;weekends (Friday & Saturday) by 1:00 am.
13. Members will not be permitted to have overnights for one week. Overnights are Friday andSaturday.
14. Members must be willing to do assigned chores.
MY SIGNATURE INDICATES THAT I HAVE READ AND UNDERSTAND ALL OF THE AFOREMENTIONED,AND IF I AM ACCEPTED, I AGREE TO ABIDE BY ALL OF THE RULES AND RESPONSIBILITIES OF THESOBER HOUSE RULES AND THAT I AM AWARE OF DISCIPLINARY ACTION WHICH COULD RESULT INIMMEDIATE DISCHARGE.
I Client first name Client last name an applicant for F.I.R.S.T. Recovery Home herebyvoluntarily consent to requests for urines and/or saliva specimen and agree to fully participate inthe weekly testing.If my specimen is found to be positive, I understand I will be immediately discharged fromF.I.R.S.T. Recovery Home.Signature:
I Client first name Client last name have read the aforementioned consent information, rules,criteria and application provided by F.I.R.S.T., Recovery Home. I understand that if I am acceptedI agree to the following terms.
1. N/A and A/A slips must be signed whenever attending meetings. They will bechecked every week by the Manager.
2. Urines are scheduled at least once per week.
3. HOUSE MEETING: Time schedule is determined by the Program Manager.
4. Curfew is in effect at all houses. Specifically: Sunday throughThursday at 11:00 p.m, Friday and Saturday at 1:00 a.m.
5. No cooking after 10 p.m.
6. All belongings must be picked up 14 days after a resident leaves the house.If belongings are not picked up during this period, they will be donated.FIRST RECOVERY HOME is not responsible or any belongings lost or stolen.
7. Smoking is done outside the house. Smoking in the house will result indischarge.
8. No loitering in front of the Buildings.
9. All rooms should be neat and cleaned every day.
10. Visitors are allowed only on Saturdays and Sundays from 12pm till 8pm.No Exceptions to the rules.
PLEASE KEEP THIS FORM.