WELCOME PACKET
Resident’s Rights
Please initial the following items to denote understanding:
Initials Text field I have the right to always be treated with courtesy and respect with consideration for personal dignity, autonomy and privacy.
Initials Text field I have the right to be verbally informed of all resident rights in a manner that I can understand.
Initials Text fieldI have the right to request a written copy of all resident rights and the grievance procedure.
Initials Text fieldI have a right to receive a written notice from A Vision For You, LLC. within 72 hours of filing a grievance.
Initials Text fieldI have the right to not be discriminated against on the basis of race, ethnicity, age,religion, gender, national origin, sexual orientation, physical or mental disability, developmental disability, genetic information, human immunodeficiency status or in any manner prohibited by local, state or federal laws.
Initials Text fieldI have the right to practice a religion of my choice or to abstain from the practice of religion.
Initials Text fieldI have the right to live in a drug/alcohol free environment.
Initials Text fieldI have the right to be informed in writing of the rates charged by A Vision For You, LLC., as well as any additional charges.
Initials Text fieldI have the right to leave/move-out of A Vision For You, LLC. at any time.
Initials Text fieldI have the right to not be locked out of the A Vision For You, LLC. at any time.
Initials Text fieldI have the right to not be locked in A Vision For You, LLC. at any time for any reason.
Initials Text fieldI have the right to privately meet and communicate with members of the Tennessee Alliance of Recovery Residences.
Initials Text fieldI have the right to file a grievance with the Tennessee Alliance of Recovery Residences at any time via tnarr.org or by emailing info@tnarr.org
A Vision For You Living Agreement
This agreement is between, Client first nameClient last name(resident/client) and manager; and/or owners and founders of A Vision For You, LLC. LLC.. Resident Agrees to voluntarily participate and reside in the recovery environment/home.
This agreement is a recommended 6 month term effective Date to Date. This agreement may be renewed or amended if agreed on and approved by A Vision For You, the resident and the community.
I commit to living at Recovery Home address:
Text field
(location of which home resident will reside)
I understand that A Vision For You LLC. is a pursuant of Tennessee Code Annotated
66-28-102(c)(1) and excerpt from the SAFE Act as written below:
Tennessee Code Annotated 66-28-102(c)(1)
· Residence at an institution, public or private if incidental to detention or the provision of medical,
geriatric, educational, counseling, religious, or similar service is not subject to the provisions of the
Uniform Residential Landlord and Tenant Act of Tennessee. In other words, this agreement is not a
lease and notice is not required by A Vision For You to discharge a Resident for violation of institution
guidelines.
TN SAFE ACT: PCA 33-2-1401(7)
"Recovery residence" means a residence classified as a single family residence, as defined in §
13-24-102, or any other premise, place, or building that provides a substance-free living environment
centered on supervised, monitored, or peer-led support that assists individuals in recovery from
substance use disorder with services that promote long-term recovery, including direct connection to
other peers in recovery, mutual support groups, and recovery support services but does not provide any
medical or clinical services, treatment, or medication administration on-site except for verification of
abstinence.
Sign:
I Signaturecommit to being a part of the AVFY community, a resident at the address listed above and to uphold my $200/week financial commitment.
Witness Signature: Signature
Date: Date
Personal Information:
Date: Date
Prior Address:Client Address
Name: Text field
Phone: Client phone
E-mail: Client email
Marital Status: Client marital status
DOB: Client birthdate
Spouse Name: Text field
DOC: Date
Emergency Contact: Contact
Sign:
I Signaturegive A Vision For You, LLC. permission and consent to contact my emergency contact, in case of emergency and to be contacted by my emergency contact.
Date of Arrival: Date
Are you currently on probation or parole? Radio buttons
Probation Officer Name: Text field
PO Phone #: Text field
Sign:
I Signaturegive consent to A Vision For You, LLC. to contact and to be contacted my probation officer.
Do you have any outstanding warrants and/or any pending charges? If yes, explain: Paragraph
A Vision For You, LLC.
Medication
Management Policy
All residents agree to:
● not to bring any narcotics or any mood-altering chemicals on the premises.
● Document all prescribed medications with A Vision For You, LLC.
● Commit to storing all prescribed medications approved by A Vision For You, LLC. in a self-provided lock box and kept locked.
● Reporting any changes in prescribed medications to A Vision For You, LLC.
● Document and report all existing and new over-the-counter medications with A Vision For You, LLC while living in the home.
If you experience any difficulty with these medications, please notify A Vision For You, LLC. and we will work together to find a solution.
Initials Text fieldI commit to not sharing any OTC and prescribed medications with other clients of the house
Initials Text field I commit to only having approved OTC and prescribed medicines on the property of A Vision For You, LLC..
Initials Text field I commit to keeping all approved medicines locked up in a self-provided lockbox.
Initials Text fieldI commit to no narcotics, mood altering chemicals, or mood-altering substances here at A Vision For You, LLC. home at any time unless prescribed by a medical professional with active oversight.
Initials Text field I consent to AVFY staff to observe me completing a pill count at any time, and I understand that any discrepancy in said pill count could result in me being asked to make a change in my living environment.
Initials Text field I consent to A Vision For You, LLC. to contact my doctors and my doctors to contact us regarding prescribed medications
A Vision For You, LLC. does not discriminate in any medical, clinical, diagnosis, or prescriptions. We subscribe and are compliant with NARR/TN-ARR standards, ethics, and recommendations for Best Practices concerning Medically Assisted Treatment.
Please list all current prescribed and over the counter medications you are currently taking:
Medication
Sign:
I Signaturegive consent to A Vision For You, LLC. to contact and to be contacted by the medical professionals listed above.
I Signatureagree to disclose changes in my medication by my doctor to AVFY staff and not to bring non-disclosed medication(s) into AVFY without previously alerting AVFY Staff. I also understand that if I choose to not uphold my agreements I may be asked to make a change in my living environment.
Grievance Policy
As a participant of A Vision For You, LLC., I understand that I have rights and responsibilities. I
am responsible for upholding the agreements I make to be a resident of this home and A Vision
For You, LLC. is responsible for providing me with a safe and supportive illicit drug and
alcohol-free recovery environment for me to grow and find a new way of life. If at any time I feel
A Vision For You, LLC. is not providing me with a safe and supportive environment, I have the
right to file a grievance and have it addressed in a timely and appropriate manner.
A Vision for You Grievance Procedure
To file a grievance at A Vision For You, LLC., I understand these steps must be followed:
If I feel I have a grievance, I will be encouraged to discuss any problems in a resident panel or
community meeting. If this method of talking out the issue is not sufficient, I will address the
complaint with the House Manager or Resident Leader. The House Manager and I will try to find
a resolution.If I am not satisfied with the results of this meeting, I have the right to file a formal
written
complaint. I also have the right to ask for help from any staff member to file the complaint. This
will be filed with HOUSE MANAGER and an appointment will be made within 72 hours. After this
discussion with staff, the decisions made at this point will be submitted to me in writing within 72
hours. I will be sent a written notice of the grievance outcome and steps for appealing the
outcome.
In the instance where the decision maker is the subject of a grievance, decision making
authority shall be delegated to Tyler Bell and/or Marshall Wilson (owner).
I have the right to contact, make a complaint and/or appeal the internal residence grievance
determination by submitting a formal grievance to the Tennessee Alliance of Recovery
Residences, the organization responsible for certification of Recovery Residences in
Tennessee.
TN-ARR P.O. Box 120114 Nashville, TN 37224
(615) 823-3864
info@tnarr.org
https://www.tnarr.org/file-a-grievance
No one shall face retribution or retaliation for filing a complaint.
Initial: Initials Text fieldI understand the above grievance policy, that I will always have
assistance available to help me file a grievance, and that I have a right to file a
grievance at any time with A Vision for You or TN-ARR.
A Vision for You Grievance Procedure Form
Grievance or Complaint:
Paragraph
Outcome from discussion of grievance in house meeting:
Paragraph
Outcome from speaking with House Manager or Resident Leader:
Paragraph
This form will be reviewed and returned within 72 hours.In the instance where the decision maker is the
subject of a grievance, decision making authority shall be delegated to Tyler Bell and/or Marshall
Wilson (Owner).
I always have the right to contact, make a complaint and/or appeal the internal residence grievance
determination by submitting a formal grievance to the Tennessee Alliance of Recovery Residences, the
organization responsible for certification of recovery residences in Tennessee:
TN-ARR P.O. Box 120114 Nashville, TN 37224
(615) 823-3864
info@tnarr.org
https://www.tnarr.org/file-a-grievance
No one shall face retribution or retaliation for filing a complaint.
Resident Name: Text field
Resident Signature: Signature
Date: Date
Staff Name: Text field
Staff Signature: Signature
Date: Date
A Vision For You, LLC.
HOUSE GUIDELINES
Name:Text field
Initials Text fieldI commit to abstain from the use of all mood- or mind-altering substances.
Initials Text field I commit to and agree to attend 5 weekly recovery based meetings
Initials Text field I understand that I am encouraged to discuss any of my concerns and issues with A Vision For You, LLC.
Initials Text field I commit to not abuse energy drinks or any other food or beverage containing high levels of caffeine, taurine, or ginseng in the house or on the property.
Initials Text field I am willing and agree to not use tobacco products inside the house. A Vision For You, LLC. has notified me of where smoking is permitted.
Initials Text field I understand and agree to not have any pet of any kind in the house or on the premises
Initials Text field I commit to obtaining a sponsor/mentor within two weeks of joining the A Vision For You, LLC. community and actively maintain a working relationship with that sponsor/mentor for the duration of my stay at A Vision For You, LLC. I also understand that if I need help finding a sponsor AVFY will assist me if I ask for help.
Initials Text fieldI commit to attend all house meetings as posted on the community board unless there is an emergency. I commit to notify AVFY staff to discuss possible solutions if any conflict arises.
Initials Text field I commit to being out of the house by 8:00am looking for a job until I secure employment, and I understand that AVFY can offer me support in finding a job if I need help.
Initials Text field I understand that I live in a community and in respect I will not cause, allow, or participate in activities that might disturb the peace and quiet of other residents.
Initials Text field I commit to upholding the following curfews and understand that the community may choose to modify them:
Sunday - Thursday 10pm
Friday and Saturday 12am
I understand that any and all changes/exceptions to curfew must be approved by staff/owners/managers and my community.
- I understand that after 30 days of residency, I may request permission for an overnight pass. This request does NOT mean that pass will be approved; and approval of passes will be on an individualized basis, and decisions on approval from AVFY staff and community that will be contingent on being caught up on rent, following of all other rules/guidelines, and meeting attendance and recovery participation
-I agree to provide 24 hours advance notice. Requesting exceptions of curfew must receive advance approval from A Vision For You, LLC.. I will include the community.
Initials Text field I understand that visitors are only permitted on the premises of AVFY with preapproval from the staff and community 24 hours in advance of the arrival of any such visitors.
Initials Text field I understand that theft is not Recovery Behavior.
Initials Text field I commit to not open or tamper with mail or packages that do not belong to myself.
Initials Text field I commit to not possess any firearms or weapons of any kind.
Initials Text field I agree to not store or consume any food or drinks in the bedrooms of the home.
Initials Text field I agree to perform daily/weekly chores as assigned and directed by A Vision For You, LLC. Recovery and the community within.
Initials Text field I agree to not flush anything other than toilet paper down the toilets
Initials Text field I understand that I am responsible for any damage that I incur to the property.
Initials Text field I agree to immediately dispose of any waste products, including but not limited to bottles, food wrappers or containers, junk mail, packaging material, dirty dishes, cups, utensils, etc. in the common areas and rooms of A Vision For You, LLC. - If I am unable to uphold this commitment, the community and staff will discuss possible solutions to provide me additional support.
Initials Text field I commit to keeping my room clean and making my bed every morning.
Initials Text field I understand that we live in a neighborhood I will turn my music down before I turn onto Walnut Crest Drive, out of respect for my neighbors.
Initials Text fieldI agree to treat other residents and the staff at A Vision For You, LLC. with respect, and if I violate, I understand that a community meeting will be held to discuss a solution immediately.
Initials Text field I am aware that violence is not safe for myself or others .. I understand that if initiate or participate in violet or negative behavior. A community meeting will be held to discuss a solution immediately.
Initials Text field I understand that I am responsible for my belongings. If I choose to leave and abandon my personal property, I am consenting to allow AVFY to donate/dispose of my things as they need to for the safety of the community.
Initials Text field I commit to have no drug paraphernalia on the property of A Vision For You, LLC. Recovery at any time.
Initials Text field I am aware. “There is always a solution” . A Community meeting can be requested. Discussion with Staff is suggested.
Sign:
I Signatureunderstand all the above agreements and choose to follow them as written. If I am not upholding my agreements, I understand that I will be given feedback. If I consistently do not uphold my agreements, I understand that I will be asked to make a change in my living environment.
A Vision For You, LLC.
Financial Transparency Agreement
Date: Date
Policy:
● At the time of move-in, each resident agrees to pay $500.00, this includes:
○ $100 application Fee
○ $400 for the first two weeks
● After the frist two weeks, each resident agrees to pay $200/week for the rest of their stay
Initial: I Initials Text fieldunderstand that I am making a financial commitment to pay $200 per week for the duration of my stay at A Vision For You, LLC..
Absolutely NO REFUNDS will be given if a resident leaves A Vision For You, LLC.
Initial: Initials Text fieldI understand that I have made an agreement that no refunds will be given from A Vision For You, LLC.
A Vision For You, LLC. will provide basic cleaning supplies such as disinfecting wipes, dish washing
detergent, hand soap, dish soap, and dish sponges. A Vision For You, LLC. will provide paper towels, toilet
paper, drug tests, and a breathalyzer.
Residents will be required to provide all personal hygiene products such as toothbrushes, toothpaste,
deodorant, body wash, shampoo, conditioner, high efficiency laundry detergent, and any other personal
care product that the resident desires.
Initial:Initials Text field I understand that I am responsible for all personal hygiene products, as well as high efficiency laundry detergent.
Sign:
I Signaturecommit to being a part of the AVFY community, a resident at the address listed above and to uphold my $200/week financial commitment.
Witness Signature: Signature
Date: Date
A Vision For You, LLC.
Drug Testing Policy
A Vision For You, LLC. is a 100% drug and alcohol-free residence.
Any use of any mind-altering substance will require intervention by staff and community.
Initial: Initials Text field I understand that no form of mind- or mood-altering substances are allowed at A Vision For You, LLC..
- I understand and agree that I have been free of any mind-altering substances for at least 72 hours before my arrival at A Vision For You, LLC..
- I am willing to be drug and alcohol tested upon my entrance to A Vision For You, LLC..
- I commit to and am willing to be drug tested randomly during my stay at A Vision For You, LLC..
- I understand and agree that a Refusal to take a drug test immediately may result in me being asked to make a change in my living environment.
- I understand and agree that if my drug test yields questionable results, I have the opportunity to take a lab test at my own expense.
Initial: Initials Text field I agree to be randomly drug tested and breathalyzed at A Vision For You, LLC..
Witness Signature: Signature
Date:Date
Recovery Contingency Plan
Please initial the following items to denote understanding:
Initials Text fieldI understand that A Vision for You has a nuanced approach to recurrence. I also
understand that I may be allowed to remain a resident of A Vision for you in the event of a
return to use.
Initials Text fieldI understand that every situation, and each person's and community's needs are
different. Each situation is addressed individually as they evolve.
● Specific recommendations may be made according to the needs of the individual and
the community.
Initials Text fieldI understand AVFY provides a safe, supportive substance-free home and that a
recurrence to use will jeopardize my ability to be a resident.
Initials Text fieldI understand that A Vision for You’s primary responsibility is to provide a safe,
supportive, substance abuse free home and commit to supporting my community by not
bringing drugs or alcohol onto the property.
Initials Text fieldI understand that A Vision for You does not have any medical or clinical staff onsite
and does not offer any drug or alcohol detox services.
Initials Text fieldI understand that AVFY is willing to work with me to come up with a solution as long
as I am willing to be responsible.
Initials Text fieldI understand that if I experience a return to chemical use and wish to continue my
living agreement, I will be suggested to have a meeting with the rest of the community to:
● Openly discuss my recurrence.
● Attempt to understand how my actions affected each resident individually and the
group as a whole.
● Inquire what peer suggestions I can follow to further support my recovery and my
community.
● Make a recovery plan that supports myself and my community.
Sign:
I Signatureagree to the above Contingency Plan and understand the steps in place should anyone experience a return to use during my time as a resident at A Vision for You.
A Vision For You, LLC. Exit Evaluation
Resident Name: Text field
Admission Date:Date
Exit Date: Date
Age:Text field
DOC: Date
DOB:Date
• Reason for Leaving: Text field
• Participated in A Vision For You, LLC. Guidelines: Radio buttons
• A Vision For You, LLC. Management Comments: Paragraph
• Plans for future: Paragraph
• Community Member Comments: Paragraph
Forwarding Address: Text field
Rent Balance: Text field
Referred to: Text field
Resident Signature:Signature
Witness Signature:Signature
Infectious diseases and Related Illnesses Liability Waiver
Date: Date
First Name: Text field
Last Name: Text field
I acknowledge that A Vision For You, LLC., has put in place preventative measures
to reduce the spread of contagious diseases but cannot guarantee that I will not
become infected with an infectious disease. I understand that the risk of becoming exposed to and/or
infected by the an infectious disease may result from the actions, omissions, or negligence of myself and
others and that infection may occur even in the absence of any negligence on the part of anyone.I
voluntarily seek services and/or residency provided by A Vision For You, LLC. and acknowledge that I am
increasing my risk to exposure to infectious diseases by the mere virtue of seeking services and/or
residency provided by A Vision For You, LLC. even when all precautions are taken. I understand that I
must comply with all the procedures set in place to reduce the spread of infectious diseases while residing
at and/or receiving the services provided
by A Vision For You, LLC.. I understand that I have the right to refuse services and/or residency at A Vision
For You, LLC. and seek services and/or residency elsewhere if I am uncomfortable with any portion of
provision in this document.
I attest that:
I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing,
fever, chills, repeated shaking with chills,muscle pain, headache, sore throat, or new loss of taste or smell.I
do not believe I have been exposed to someone with a suspected and/or confirmed case of an infectious in
the last 21 days.I have not been diagnosed with an infectious disease and am cleared asnon-contagious
by state or local public health authorities.I am following all CDC recommended guidelines as much as
possible and limiting my exposure to any/all infectious diseases.
I hereby release and agree to hold A Vision For You, LLC. harmless from, and waive on behalf
of myself, my heirs, and any personal representatives any and all causes of action, claims,
demands, damages, costs, expenses and compensation for damage or loss to myself and/or
property that may be caused by any act, or failure to act of the residence, or that may otherwise
arise in any way in connection with any services received from A Vision For You, LLC.. I agree
to waive the right to litigate in court or arbitrate any claims or dispute as a class action, either
as a member of a class or as a representative. I understand that this release discharges
A Vision For You, LLC. from any liability, claim and class claim that I, my heirs, or any
personal representatives may have against A Vision For You, LLC. with respect to any bodily
injury, illness, death, medical treatment, or property damage that may arise from infectious
diseases in connection to, any services received and/or residency at A Vision For You, LLC..
This liability waiver and release extends to A Vision For You, LLC. together with all owners,
partners, and employees of A Vision For You, LLC..
Sign:
I Signature understand the above policy and agree to hold A Vision For You, LLC. and associates harmless in the event of any and all infectious disease(s).