Admit Date: Date
On this day, this Agreement is between Empowering Potential Housing
and Client first name
Client last name
hereinafter referred to as Family Resident.
General Services Provided: Empowering Potential Housing has homes for women and men ages 18 and older with a chemical dependency and a disease of addiction. Empowering Potential Housing provides a home-like atmosphere and environment to enhance sober living skills.
Empowering Potential Housing provides the following general services:
· Alcohol and drug recovery information
· Shared room lodging
· Facilities for meals and personal laundry
Family Resident’s General Responsibilities: Family Resident agrees to make a minimum ninety-day (90) commitment of residency and provide at least thirty-day (30) notice prior to leaving. In addition,
Family Resident is required to accept the following general responsibilities:
· Refrain from using or possessing alcohol, and/or other mind-altering chemicals, drugs, or drug Paraphernalia.
· Attend ALL Mandatory In-House meetings. Generally, this includes a general Family Resident weekly house meeting, along with 3 Recovery Meetings (if sober 6+ months) or 4 Recovery Meetings per week (up to 6 months sober).
· Act as a sober peer to other Family Residents, both through active participation in recovery activities and demonstration of positive sober attitude.
· Notify house leader/senior resident promptly in the event of sickness, physical problem, or injury.
· Inventory and store all medications in a lockbox (self-provided) and take all medications as prescribed. Resident agrees to notify Empowering Potential Housing of any new or refilled prescriptions within 48 hours in order to maintain accuracy of your file.
· Comply with any house restrictions and abide by all curfews.
· Do not discriminate - we are LGBTQ friendly homes. We expect all residents to respect others.
· Take care with and avoid damage to facility property, furnishings, and equipment.
· Perform regular assigned household duties (daily chores).
· Maintain personal cleanliness and upkeep of living space.
· Abide by all other house rules, regulations, guidelines, standards, and policies.
Family Resident Discharge: Upon discharge from Empowering Potential Housing Sober Living, Family Resident agrees to leave the premises, property, and facilities immediately. Family Resident agrees not to return to the premises, properties, or facilities of Empowering Potential Housing or contact other Family Residents at the facility, without written permission from the Operator.
Family Resident understands Empowering Potential Housing shall have the right to discharge and require the Family Resident to leave the facility immediately for not following the Rules (RED type = immediate dismissal from home)
· Empowering Potential Housing determination that a Family Resident is not suitable.
· Family Resident requires care that is not provided by Empowering Potential Housing
· Family Resident requires immediate medical or psychiatric evaluation, medical or nursing care.
· Family Resident uses or possesses alcohol, and/or other mind-altering Chemicals, drugs, or drug paraphernalia.
· Family Resident refuses to submit to a urinalysis process and procedures within two hours of request by house leadership.
· Family Resident violates curfew or is absent without an authorized pass.
· Family Resident commits any act that is a crime under federal, state, or local law.
· Family Resident exhibits behavior that is inappropriate, dangerous, and violent or a threat to house leader/senior resident, self, or others.
· Family Resident fails to pay program fees or other fees in accordance with this agreement.
· Family Resident exhibits disregard for or failure to comply with any rule, regulation, guideline, standard or policy.
· Family Resident is unwilling or unable to comply with house rules and has been given an opportunity to correct behaviors with a behavioral contract.
Personal Property: Empowering Potential Housing reserves the right, at its sole discretion and determination, to deny certain personal items into the facility on the basis that they are inappropriate, dangerous, problematic, or take up too much space. Any clothing or other personal items that cannot be stored neatly in provided closets, drawers, or shelves are not permitted. Personal furniture without prior approval is not permitted. Off-street parking is provided as available, and Family Resident agrees not to own or maintain more than one vehicle titled in their name, in neighborhood. Pets are not permitted - Family Resident will refrain from harboring, feeding, or allowing any animal inside, outside.
Inspection of Personal Items: Family Residents grant to Empowering Potential Housing permission to inspect, at any time, all belongings, personal items and general living space for any liquor, drugs, or drug paraphernalia, weapons, or items determined by Empowering Potential Housing to be dangerous or inappropriate. In addition, Family Resident grants Empowering Potential Housing permission to remove and dispose of any such items found during inspection.
Removal of Personal Property: Upon discharge, Family Resident agrees to remove all personal property immediately (if not home Family Resident allows for management to pack items on their behalf). Family Resident understands and agrees Empowering Potential Housing may dispose of all personal property left on the premises for 24 hours following discharge. Upon discharge, Family Resident is encouraged to submit change of address to the U.S. Postal Service for mail service to the provided PO Box. Empowering Potential Housing assumes NO responsibility for mail delivery (at any time to homes) and Family Resident understands mail will not be held or forwarded on their behalf.
Room Assignments: Family Resident agrees to comply with room assignments.
Drug Testing: Family Resident understands and agrees Empowering Potential Housing may perform breathalyzer, salavia, and/or urine testing at any time with or without cause. Family Resident agrees to submit to the testing process and procedures - a refusal to test is the same as a fail.
Facility and Furnishings: Furniture, window coverings and other room amenities may not be moved or rearranged. Family Resident may not attach anything to windows, doors, walls, furnishings, or any other part of the facility. Family Resident agrees to immediately assume the full cost of replacement or repair to facility, equipment, and furnishings caused by accident, misuse, or negligence.
Liability: Family Resident will hold Empowering Potential Housing Recovery Residences, employees, management, house leader/senior resident, and volunteers harmless and free from all liability for losses through fire, theft, or personal injury while in, on, or about the premises, property and facilities and/or while being provided transportation and/or while participating in any activities both inside and outside the premises, property and facilities of Empowering Potential Housing Recovery Residences.
Personal and Medical Information: Family Resident grants permission to any doctor, hospital, institution, or attorney or agency to provide all personal and/or medical information to Empowering Potential Housing Recovery Residences.
Nondiscrimination: Empowering Potential Housing does not discriminate, nor will permission be denied based on ethnic group identification, religion, age, sex, color, or disability.
Registration Requirements: Prior to admission or upon any subsequent notice, Family Resident agrees to disclose Empowering Potential Housing any law enforcement registration requirements such as PC290, or any other registration requirements. Failure to disclose such requirements are grounds for immediate termination. In accordance with Empowering Potential Housing policy and state law, PC290 registrants are prohibited from enrolling or participating.
Reporting Requirements: Family Resident understands that in compliance with federal, state, and local laws Empowering Potential Housing is required to report to the appropriate authorities, all incidences of child abuse, elderly abuse and harm to self or others. Furthermore, Family Resident understands and agrees progress reports may be given to the Court Officials, Parole and Probation Departments, if applicable as required or requested.
Program Fees and Payment Schedule: The monthly fee is $1,000 + $100 non-refundable move-in fee. Unless special financial provisions are agreed upon below, the total monthly fee is due immediately upon admission and on the same day each subsequent month. Program fees are due in advance and are non-refundable. INITIAL UNDERSTANDING- Initials Text field
Late Fees: A late fee of $25.00 will be assessed to any account that is not paid in full by the 3rd of each month following the due date.
Utilities: Utilities are included as part of the program fees paid. Included utilities are limited to gas, electricity, water, sewer, internet, landline and rubbish.
House Fund: Family Resident is responsible, along with other house members, for an equal portion of any house fund established by house members to cover Incidental household bills and expenses. House fund fees are non-refundable. EMPOWERING POTENTIAL HOUSING IS NOT RESPONSIBLE FOR ANY HOUSE FUNDS.
Refund Policy: All program monthly and move it fees are non-refundable. Family Resident understands that if discharged for non-compliance with this agreement, or if Family Resident voluntarily leaves for any reason without thirty-day (30) notice, or Family Resident fails to be admitted on scheduled admission date for any reason, Family Resident will not automatically receive a refund for any fees paid. If bed is filled, Empowering Potential Housing may refund a prorated fee from the date a new resident takes the bed.
Special Financial Provisions (must be pre-approved by Empowering Potential Operator):
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Special Conditions:
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Acknowledgement of Terms and Receipt: My signature below, as Family Resident, indicates that I have read, or had read to me and explained the provisions of this Agreement. I agree to and will comply with all the terms, provisions, and conditions of this Agreement. Further, I acknowledge the receipt of a copy of this agreement.
FAMILY RESIDENT:
Print name: Client first name Client last name any nickname? Client nickname
Signature: Signature
TODAY'S DATE: Date
HOUSE RULES
(RED TYPE = IMMEDIATE REMOVAL FROM HOME)
You are in a Recovery Residence. Your success and continuance in this environment are dependent upon your consistent good behavior and cooperation. Disruptive and/or discourteous behavior will not be tolerated. Any contact with Illicit drugs and/or alcohol and/or violation of any of the following rules may result in dismissal. Your signature below indicates your understanding and agreement to abide by these rules.
SAFETY:
INITIAL MEANS YOU READ AND WILL COMPLY -
Initials Text fieldNo loitering or hanging out in the front yard for any reason including waiting for Uber/Lyft. If you want fresh air or to smoke, use the back yard.
Initials Text fieldKeep entry and exit doors closed and locked at all times.
Initials Text fieldKnives, Guns, Tasers, Brass knuckles, any other weapons, drugs or paraphernalia etc. are not permitted AT ANY TIME! If found, items will be removed, and dismissal may be issued.
Initials Text fieldMedication should always locked away - excluding when it is time for self-administration. You must immediately return medication to locked container following self-administration. Resident agrees to notify Empowering Potential Housing of any new or refilled prescriptions within 48 hours in order to maintain accuracy of your file.
Initials Text fieldDo not leave items on the floor that may cause a slipping or trip hazard.
Initials Text fieldEveryone entering the home needs to sign in and out on the log white board.
Initials Text fieldNo (lit) candles, incense, or fires (even in fireplaces) except for decoration.
Initials Text fieldDo not lock or block doors – bathroom door is fine but note we will check on you if extended time.
BEHAVIOR:
Initials Text fieldNo aggressive or violent behavior EVER!
Initials Text fieldNo profanity or offensive language directed or romantic advances on others in home.
Initials Text fieldNo sex of any type (including masterbation) anywhere in/near/or by the home. NO using the house computer for pornography!
Initials Text fieldNo video, photography or video chat (Facetime) inside the home at any time unless the subject is ONLY you. Video chats should not be conducted in a bedroom unless you've confirmed you are the ONLY person in the room, should be on headphones, and always respecting people's anonymity and privacy.
GENERAL:
Initials Text fieldHouse Leader/Senior Resident may inspect in and around bedroom property or belongings at any time and within reason, for the safety and protection of all residents.
Initials Text fieldDo not steal or use another person’s items without permission.
Initials Text fieldResidents are discouarged from sharing or loaning personal property or MONEY to other residents - do NOT discuss how much money you have with others or what medications you are on - respect your privacy.
Initials Text fieldDo not open or enter any cabinets or closets with locks.
Initials Text fieldTurn lights/TV/fans off when not in use.
Initials Text fieldUse headphone or phone - not the speaker for video/phone calls
Initials Text fieldYou may NOT enter another resident's room at any time.
Initials Text fieldKeep bedroom doors always closed.
Initials Text fieldClothes and shoes/slippers must be worn outside of your room.
Initials Text fieldNever leave personal items unattended in common areas.
Initials Text fieldIf you are diabetic or need to give yourself shots using a syringe, you will need to have a medical grade bin to dispose of used needles properly.
Initials Text fieldSleeping in common areas is prohibited.
Initials Text fieldGroupMe is required and joining the house thread, as long as you have a smart phone.
Initials Text fieldUse the company provided PO Box for incoming mail = 7107 Broadway #233, Lemon Grove, CA 91945
Initials Text fieldThermostat is to be adjusted by the House Leader/Senior Resident only (76 summer AC/68 winter heat - if applicable)
Initials Text fieldHouse Meetings are generally held on Saturday from 9am -10am (or modified by House Leader/Senior Resident) and are mandatory for every resident. Prior to house meeting is a 2 hour “double scrub” of the house which is also mandatory. Each home may hold a group conscious and change the house meeting to a Sunday or Monday evening due to the needs of the residents of that home.
CURFEW:
Initials Text fieldFirst 14 days in home curfew is 10pm every night.
Initials Text fieldAfter 14 days in home curfew is 11pm every night and midnight Friday and Saturday. Failure to return to the house on time can/will result in dismissal.
Initials Text fieldHouse quiet time is 10:00pm to 6:30am - any activity (lights, TV, phone conversations, cooking food, showering, etc.) that disturb another resident’s ability to sleep/rest is prohibited.
OVERNIGHT PASS/GUESTS:
Initials Text fieldOvernight/weekend passes are to be submitted on the house computer after you've received approval from the House Leader/Asst House Leader at least 24 hours in advance. You must be in compliance with ALL house rules before approved and you must have been in the home for a minimum of 14 days. If you test positive for any drug/alcohol on UA/BA, you will not be allowed to have ANY overnight pass for 60 continous days after positive test.
Initials Text fieldIf you are being paid for by an IOP/program that will not fund overnights you will need to pay Operator directly for any night gone from home as we cannot bill funding source for those missing nights. You must log the missing nights on the REQUIRED Overnight Request Form!
Initials Text fieldAdult guests are only allowed in the backyard of the home to visit (or to share a meal at the dining room table with leadership approval):
up to 2 hours Monday-Friday 6pm - 8pm
up to 2 hours Saturday-Sunday noon – 8pm
Initials Text fieldChildren (age 17 or less) are allowed to visit:
up to 6 hours Monday-Friday 10am - 8pm
up to 6 hours Saturday-Sunday noon – 8pm kids ages 12 and less are allowed in the common areas of the home along with backyard.
Initials Text field NO ANIMALS ARE ALLOWED due to other participant allergy concerns, flea infestations, sanitary issues, concerns over animals fighting or the general safety of others.
SMOKING, ALCOHOL, AND DRUGS:
Initials Text fieldConsumption or possession of alcohol in any form is strictly prohibited.
Initials Text fieldUse or possession of illicit drugs in any form is strictly prohibited.
Initials Text fieldUse and/or possession of drugs and/or alcohol on site will result in immediate dismissal.
Initials Text fieldLying, cheating, and stealing are strictly prohibited. If caught, will result in immediate dismissal.
Initials Text fieldAll are required to submit to a drug and alcohol test at any time as per request. A refusal and/or failure to provide an adequate sample will be treated the same as a positive test result. Any attempt to cheat/circumvent a test will result in a dismissal.
Initials Text fieldSmoking/vaping inside the home is strictly prohibited. Smoking/vaping is allowed in a back patio area away from door, windows and play spaces except during quiet hours of 10p-7a. This is a smoke free residence.
DAILY HABITS:
Initials Text fieldDaily attendance at a Recovery meeting is strongly encouraged; the minimum daily attendance requirement is 4 per week (sober less than 6 months) or 3 per week (sober 6+ months) and will be tracked.
Initials Text fieldYou are encouraged/recommended to maintain a Home Group.
Initials Text fieldYou are required to maintain a working relationship with a Sponsor.
Initials Text fieldYou are required to maintain employment or go to school. If at any time you become unemployed or not enrolled in school and you’re capable of working (not injured or sick), you’re required to actively seek employment from 9:00 am - 5:00 pm Monday through Friday. Your employment is prohibited from interfering with their adherence to any of the other terms of this agreement.
Initials Text fieldBehavior considered to be a “conflict of interest” (i.e., employment, dating, etc.) between residents is prohibited.
Initials Text fieldAttendance at house double scrub and weekly house meeting is mandatory! Only 1 absence is allowed every quarter (planned overnights, called into work, etc.)
Initials Text fieldSign in and out on the white board EVERY time you leave the home.
CLEANLINESS:
Initials Text fieldPut trash in the trash can, wash dirty dishes and put in dishrack, clean up after you use the bathroom, make your bed, put up your clothing and items
Initials Text fieldYour room shall be kept in an orderly and sanitary condition at ALL times – wash bedding 1x per week.
Initials Text fieldFood is only to be consumed in the dining room areas only. Food is NOT ALLOWED in bedrooms at any time. No dishes left in the sink and wipe down counters, stove, etc. of your mess.
Initials Text fieldIf you spill anything or make a mess anywhere in the house including your room, you will be responsible for cleaning it up.
Initials Text fieldKitchen appliances, counter-tops, utensils, dishes, pots, pans, etc. will be cleaned and returned to their respective place (immediately) after each use.
Initials Text fieldRefrigerator – All food must always be covered or be put in a storage container.
Initials Text fieldChores are required to be completed daily. The House Leadership is responsible for chore assignment and completion. Failure to complete assigned chores can result in dismissal.
Initials Text fieldA good general clean-up of all areas inside and outside the home is required at all times.
YOUR ROOM:
Initials Text fieldYou may NOT enter another resident's room at any time.
Initials Text fieldMattress covers must NEVER be removed.
Initials Text fieldKeep bedroom doors closed and personal items inside of your room (valuable items should be secured).
PERSONAL HYGIENE:
Initials Text fieldTampon, sanitary pads, adult diapers, etc. must be wrapped in tissue or a bag and placed in trash receptacles properly.
Initials Text fieldYou shall keep up with your personal hygiene by bathing and brushing your teeth frequently along with putting on clean clothing and wearing footwear while in the common areas.
Initials Text fieldYou shall have no complaints that you or your personal space has offensive odors.
Initials Text fieldYou will take responsibility for their own health and respect the health and safety needs of all other residents and will take precautions (hand washing, extra cleaning of surfaces, limiting interaction with other residents, appointment with a physician if necessary) when aware of or experiencing exposure to bodily fluids and communicable diseases.
LAUNDRY:
Initials Text fieldUse of Laundry may be on scheduled day and time. All laundry must
Initials Text fieldLaundry area must be clean and all clothes removed by YOU.
Initials Text fieldLast load of laundry started by 9pm so as to be completed before quiet hours
Initials Text fieldYou may not wash another person’s clothes.
Initials Text fieldYou may not put feces soiled items into any washer or dryer in the home.
DURING THE DAY:
Initials Text fieldYou agree to each of the following (check all that apply):
Initials Text fieldBe up and out of bed by 9am and have house chore done before 10am and room chore done by 10pm
Initials Text fieldWork, go to school, or volunteer outside of the residence
Initials Text fieldParticipate in aid or caregiving of children or elderly
Initials Text fieldParticipate in social, physical or creative activities
Initials Text fieldParticipate in daily or weekly community activities
Initials Text fieldYou are NOT to sit and watch TV all day unless an illness or injury prevents you from engaging in activities above
CHECK SYSTEM, CHECK-INS FOR NEW ARRIVALS AND MEETINGS WITH HOUSE OWNERS:
Initials Text fieldAs you get acclimated to the home you are required to text the house leader(s) whenever you leave the home for the first 14 days whiche helps build a relationship and mutual trust.
Initials Text fieldAs you get acclimated to the home you will be given verbal warnings for the first 14 days when not in compliance with house rules listed (for those not in RED anything in RED you are subject to immediate dismissal).
Initials Text fieldAfter 14 days when you violate a house rule for each 7-day period starting on Friday and ending on Thursday
Initials Text fieldYou will receive ONE CHECK = ONE CHORE HOUR
Initials Text fieldWhen you violate a 2nd house rule over those same 7 days you will receive a SECOND CHECK = loss of OVERNIGHT privilege for upcoming weekend and 2nd chore hour.
Initials Text fieldWhen you violate a 3rd house rule over those same 7 days you will go on a BEHAVIORAL contract, lose OVERNIGHT privilege for the upcoming 2 weekends and receive a 3nd CHORE HOUR.
Initials Text fieldHouse leadership is your first line to solve issues and always have an open-door policy for grievances. Should you wish to speak to the owners you MUST schedule a time through the House Leaders to meet with you, the leader and either owner.
Rules are subject to change at any time and can be modified by management to accommodate different situations.
No possessor rights are granted or intended by this agreement. In the event the resident is unable to abide by the policy and rules, by my signature below, you agree to immediately vacate the property.
My signature signifies that I have read and understand what I can and cannot do while living in Empowering Potential Housing. I understand and agree that if I break any rules within this document, my stay will be terminated immediately, and I will be banned from living in other homes that Empowering Potential Housing manages.
Print Name Client first name Client last name
Signature: Signature Date: Date