Intake Form & Contract


Acceptance Homes Intake Form & Contract

Welcome to the Acceptance Homes intake wizard!
Click next to begin!


Tell us about yourself

What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Contact Information

How can we reach you?

What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
Client City
Client State
Client Zip
Text field


Give us a few people that we can reach out to in case of an emergency.

Please provide their phone number:
Text field


Enter your insurance provider(s).

Enter your SSN 

Medical History

Tell us about your medical history.

When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests


List the medications you are currently prescribed. (Failure to list all medications will result in dismissal)


Treatment Centers

Tell us about any treatment centers you've previously been admitted into.


Client Referral Source


Who referred you to us?
Client Referred By



Do you have the means to support yourself for 2 weeks until funding gets approved or can you ask family/friends to help?
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
When will you be discharged?
Client discharge date
What's the best number to reach you at there (Counselor Number and Extension)?
Text field

Recovery History

Tell us about any sober livings you've previously been admitted into.

Have you ever had suicidal thoughts? Dropdown

Have you ever had homicidal thoughts? Dropdown

Do you consider yourself an addict/alcoholic? Radio buttons

What's the longest you've been clean before? Text field


Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"


Living Arrangement

Tell us about your living arrangement prior to moving into this facility


Legal History

Are you required to register as a sex offender or do you have charges for arson?

Do you have warrants for your arrest?

Do you have a probation or parole officer?

Please provide their contact information, if you have one:


Application Agreement and Signature

Attestation - I attest that all of the information is complete and accurate. I acknowledge that failure to provide complete and accurate information could result in legal consequences including, but not limited to, termination of residency from the Acceptance Homes LLC program.

Release of Information - By signing below, I am providing my approval for Acceptance Homes LLC releases to discuss my medical, treatment, and progress information with my probation/parole officer (if applicable), my emergency contact, the counselor listed above, WestPARR Staff, Ryan's Wings Staff, and the staff of the Department of Drug and Alcohol and the subsidiary counties.

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.


Printed Full Name: Client first nameClient last name

Today's Date: Date


Please continue on immediately to the contract below.


Resident Rights

The following terms and agreement are to be read and fully understood by the undersigned resident of the Acceptance Homes, LLC program.

1. Acceptance Homes LLC is providing the undersigned resident a place to reside at an Acceptance Homes LLC location in New Castle, PA at either 413 N. Jefferson St New Castle, PA 16101 or 427 Uber St in return for a Program Fee as mentioned below.

2. The undersigned understands that they shall live in the facility under the agreed upon contractual terms and rules as provided and explained and may terminate their residence at any time.

3. Acceptance Homes LLC will provide a housing facility in normal condition and shall not be held liable by the undersigned for any injury or loss to the tenant, or their belongings. The undersigned, by and through their signature, acknowledges that they are responsible for any injury or accident and will forever hold harmless Acceptance Homes LLC unless said provider is negligent in the cause of the loss.

4. The undersigned understands that Acceptance Homes LLC carries only insurance to cover the dwelling and business assets located in the dwelling.

5. The undersigned may contact the Department of Drug and Alcohol Services at Department of Drug and Alcohol Programs to file a complaint regarding any of the contained violations of rights.

6. The undersigned will immediately notify Acceptance Homes LLC, in writing, of any incident resulting in

injury or loss. This will include a full accounting of the incident details.

7. The undersigned resident retains all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.

8. Acceptance Homes LLC does not discriminate against an individual or staff based on age, race, sex, religion, ethnic origin, economic status, sexual orientation or gender identity or expression or disability.

9. Residents have the right to inspect their own records.

10. Residents have the right to request the correction of information in their records on the basis that it is inaccurate, irrelevant, outdated, or incomplete.

11. Residents have the right to submit a rebuttal to information in their records.

12. Residents may attend a treatment facility of their choice outside of the drug and alcohol recovery house. Acceptance Homes LLC does not require a resident to attend a specific treatment facility.

Initials Text field

Contract of Residency

This document serves as your Contract of Residency and Resident Handbook with Acceptance Homes LLC. You are voluntarily agreeing to enter the community and program of Acceptance Homes LLC. Sharing residency with other recovering residents and maintaining complete abstinence is part of the program. Acceptance Homes LLC has two locations at 413 N. Jefferson St. New Castle, PA 16101 and another at 427 Uber St New Castle, PA 16101.

At the end of the document, a signature section is provided for acknowledgement that all house rules, requirements, and guidelines are acceptable and will be adhered to by the resident. Failure to follow the house rules, requirements, and guidelines will result in corrective action, up to and including, infractions and/or Termination from Residency (TFR).

Financial Expectations

1. Program Fee is $425 per month at 413 N Jefferson and $500 per month for single rooms or $450 for shared rooms at 427 Uber St. This fee is Non-Refundable. If applying for county funding, be sure it is scheduled to start on the last resident-paid date. If funding starts before self-pay has been exhausted, the remaining days are added to the end of the stay.

2. The due date is the first day of the month unless otherwise arranged in writing due to extenuating circumstances such as social security payment dates.

3. There is a $5 per day late fee for each day the Program Fee is delayed past the due date. The bank being closed is not an excuse for failure to pay the program fee; please plan accordingly.

4. Failure to pay the program fee by 5 days after the due date each month, may result in Termination from Residency (TFR).

5. The first month of the Program Fee will be prorated to the number of nights left in the month. If there is less than 7 nights left in the month, the next month must be paid along with the remainder of the current month. In the rare circumstance that a resident is allowed to move in without upfront funds, they are required to repay the owner for the days spent at the house within 30 days of entry.

6. If a resident should leave or get TFR in the middle of the month, the Program Fee is non-refundable and will not be prorated back to the resident. If you plan to leave, please provide as much notice as possible.

7. Unless funding is provided by LCDAC or a government entity, the form of payment for Program Fee shall always be a money order or a cash deposit to the Acceptance Homes LLC account at First National Bank of PA. You must get and keep a receipt for your transaction for proof of payment. Upon making the payment, email a picture of the receipt to with your name.

8. In the unfortunate event that a resident relapse, the Program Fee is non-refundable. Residents will be referred to LCDAC for a treatment evaluation. Pending the results and compliance with the treatment plan, readmission to the house will be determined through mutual agreement and cooperative effort between LCDAC and Acceptance House Management.

9.  At no point will Acceptance Homes LLC require residents to relinquish the resident's public assistance benefits, including medical assistance, cash assistance, SSI, or SNAP benefits

10. At no point will Acceptance Homes LLC require a resident to surrender cash or sign over a paycheck.

11. At no point will Acceptance Homes LLC borrow money from or loan money or property to a resident.

12. At no point will Acceptance Homes LLC directly or indirectly solicit or accept a commission, fee, or anything of monetary value from residents, other related individuals, third-party entities, or referral sources beyond rent established in writing at the time of residency.



As a resident of Acceptance House, there are specific action that will be cause for immediate TFR from the program and residence. Any TFR resident must leave the premises within 1 hour. The Resident that has been Termed from Residency must arrange to have any remaining items picked up from the location within 48 hours or they will be donated unless special arrangements are made with the house supervisor. This list of TFR infractions is not exclusive and may not list every circumstance that will result in TFR.

1. Using Drugs or Alcohol - This includes, but is not limited to, THC, Delta 8, Hemp, CBD products, K2, Spice, Kratom, etc.

2. Stealing (including food)

3. Smoking or Vaping within the building

4. Violence or Threats of violence of any kind

5. Arson of any kind.

6. Possession of Drugs or Drug paraphernalia - This includes, but is not limited to, THC, Delta 8, Hemp, CBD products, K2, Spice, Kratom, etc.

7. Refusal to take a drug screen

8. Intentional Destruction of Property.

9. Failure to pay Program Fee by the resident’s due date each month.

10. Sharing Prescription Medication

11. Exceeding the correct dose of prescription medication

12. Use of any non-approved medication

13. Providing anyone outside of the program with the lock code to the house.

14. Breaking confidentiality of any resident or the management of the house

15. Possession of any weapons



Medication Control and Self Administration – Drug Use Policies

This section discusses the rules surrounding prescription medication as well as the use, prohibition, and testing for illegal drugs and alcohol within the Acceptance Homes LLC facility.

1.  Consumption or Possession of Alcohol in any form is strictly prohibited and will result in TFR (Termination from Residency).

2. All clients on Medically Aided Treatment (MAT) which included but is not limited to Suboxone, Methodone, etc. must self-administer daily. A week’s amount is not provided to residents at the residence. Additionally, if signs of abuse are present, a request may be made by the house supervisor for a medication level check to be performed at Jameson's WorkHealth program at the resident expense. A release must be signed for permission for the house supervisor to receive the results of the levels. If the levels are over the allowable limits, you will be terminated from residency and a referral to Drug and Alcohol will be made for more treatment options. If the results prove, undoubtedly, that the medication was taken as prescribed, the house will reimburse for the test and allow the resident to stay.

3. All clients must disclose all medications. All medication is locked up behind two locked doors, tracked, and self-administered.

4.  During medication self-administration, residents will sign off on the disbursement and remaining pill count. Non-narcotic medication is provided in 7-day increments and counted out by residents themselves into pill containers. All residents are subject to random pill counts and failure to participate in this expectation is grounds for removal from the program. Failing a pill count is also grounds for removal.

5.  All prescription drugs must be disclosed upon intake or by direct communication with the House Supervisor prior to filling a newly prescribed medication. Upon return to the house, the New Prescription tracking sheet must be completed for documentation purposes. Failure to disclose and submit medications to locking/safeguarding will result in TFR.

6.  Sharing medication is prohibited and will result in immediate TFR.

7.  Taking more than the prescribed dosage will result in immediate TFR.

8. Use and/or possession of drugs and/or alcohol will result in immediate TFR. If TFR for drugs and/or alcohol the resident agrees to leave the premises immediately and not return for any reason whatsoever without permission from the House Supervisor or Acceptance Homes LLC. If a resident is too intoxicated to safely leave the house, transportation to Jameson hospital or Lawrence County Drug and Alcohol Committee (LCDAC) only can be made available.

9.  Residents are required to submit to a Drug and Alcohol Screen/Test at any time (24 hours a day, 7 days a week) if it is requested. 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 the test will result in an TFR. The tests will be administered by either a House Supervisor, another member of the residence such as a floor captain or another volunteer, or the owner. A witness may also be present as a secondary witness as necessary.

10. Acceptance Homes LLC can and will test for every type of drug including but not limited to K2, fentanyl, suboxone, and methadone. The drug and alcohol tests will vary from 12 panel to individual drug tests.

11. All residents of Acceptance House, including all support staff are required to complete drug overdose reversal and Narcan training within 7 days of admission. Narcan is located on every floor of the house – in the closet hutch in the living rooms.

12. If medication is not taken upon graduation or termination of residency, the medication will be held for no longer than 30 days. It will be held in the locked same locked area as the rest of the medication and remain tracked on the medication tracker. It will then be disposed of based on the Federal Regulations outlined in bullet 13 below.

13. All unused, expired, or abandoned medication will be disposed of in accordance with State and Federal Regulations outlined at or at the Hyde Drug Store disposal center.

14. Missing medication – If medication is missing, a full medication log audit will be conducted and accountability for discrepancies will be initiated. As necessary, changes in processes such as additional witnesses will be added until the variance can be corrected. Cameras can be installed in the pill distribution area for added security measures. If the situation is that the medication is missing due to a break in or robbery of the locked medication area, the authorities will be involved, and a police report will be filed.

15. In the event of an accidental overdose of medication, an ambulance and poison control will be called immediately. An ‘unusual event’ will be logged with the department. If warranted, such as intentional overdose for the purposes of getting high, the resident will be terminated from residency. In the cases of intent being tied back to mental health, a psychiatric referral will be made.



In this section, the expectations regarding participation in 12 step programs are outlined.

1.  Each resident must have a sponsor and homegroup in one of the fellowships (Narcotics Anonymous, Alcoholics Anonymous, or Celebrate Recovery) by the end of their first full month in the house.

2.  Meeting slips must be signed by all residents during their first 90 days of clean time or if the House Supervisor deems it necessary at any time. Sheets must be turned in weekly to the House Supervisor's office with the Resident's name.

3.  Participation in the selected homegroup is mandatory weekly.

4.  During the first 30 days of clean time or a direct transfer from a rehab or jail, a resident must attend an average of 5 meetings per week.

5.  Between the clean time of 31 days to 6 months, residents must attend 4 meetings per week.

6.  From 6 months to 2 years clean time, residents must attend 2 meetings per week.

7.  After 2 years of clean time, residents must attend 1 meeting per week and 8 per month.

8.  All residents must maintain a working relationship with their sponsor and work steps.

9. One Step Software must be used to check in and out of meetings unless the resident does not have a cell phone whatsoever. With two methods of tracking meeting attendance, there is a zero tolerance policy for lack of documentation around meeting attendance. 

While these rules and guidelines are in place to promote strong recovery, any addict is ultimately responsible for their own recovery. Acceptance Homes LLC does not guarantee clean time or recovery and is not held liable for a relapse or the consequences of a relapse. If you feel as though you are going to relapse, be sure to use your resources such as your sponsor, meetings, support group, and Lawrence County Drug and Alcohol Commission. No addict need die from the horrors of addiction. You never have to use again.



1. Surveillance cameras are installed in common areas of the building in case of emergency or escalated issues. By agreeing to this section, you are agreeing to be recorded by audio and video with these cameras and the footage to be stored on the cloud. Additionally, you agree to not use any other recording devices, including but not limited to audio, video, or photography without consent of those being recorded. It is also a breach of confidentiality based on this clause.

2. Smoking within the building, “out the window," and in the front or on the sides of the building is also prohibited. Failure to comply with this will result in TFR.

3. There is one common area located on the first floor which is a public space. With that, this is not a confidential area. You are not permitted in this area between the hours of 8am and 5:30pm except on Sundays. During that time, use the living rooms on each floor. You may not talk about the ongoings of the house while in the public common area.

4. The use of any household item such as the washer/dryer, weight sets, TVs, pool table, etc. should be limited to 1 hour to avoid conflict between residents.

5. Washer/Dryer is coin operated. Be respectful of its use and clean the lint trap. Avoid leaving unattended clothing sitting and waiting.

6. While there will always be at least one tv within the house for use and one washer/dryer combo, the presence of an extra washer/dryer, pool table, or a "big screen" tv will be a luxury frill of the house which means that if they are destroyed, Acceptance Homes LLC is not responsible to immediately replace these luxury items. Use them with care.

7.  Overnight Passes are to be submitted to the House Supervisor a minimum of 72 hours in advance. Authorization will be granted at the discretion of the House Supervisor. A fee of $10 per overnight is required to pay for a mandatory drug test upon return. Residents must have over 30 days of tenure in the house before taking an overnight pass. Emergency exceptions can be submitted to house management for approval with physical proof of the emergency. The limit for overnight passes is 5 total nights per calendar month. Only one “weekend” which is two consecutive days can be taken per calendar month. If a more than 2 nights are needed away from the house, it must be submitted 1 month in advance.

8.   Turn off all lights, appliances, fans, radios, etc. when not in use. Exterior doors and windows must always remain closed except when entering or exiting the building.

9.   House Lock Code cannot be given to anyone outside of the house and the code shall be changed upon TFR of any guest. This will result in TFR if not adhered to.

10. Mark food/leftovers with Name/Date when put in the refrigerator.

11. Appropriate clothing must always be worn in common areas.

12. The lock code of the house will be changed any time someone is TFR.

13. House Ownership has the right to change the rules and guidelines at any time they deem necessary for the benefit of everyone.

14. Right of Entry - House Owner, Manager, Supervisor, and is permitted to enter the home at any time for inspection and tours from new residents, prospective building buyers, code inspections, etc.

15. You will be provided with linens, blankets, cleaning supplies, and paper products. Please use these respectfully. Linens and blankets must remain in their respective rooms. Residents are responsible for washing their own linens. Clean linens and comforters will always be provided to new residents. All Mattress protectors must stay on the beds. You may not cut off fire-retardant tags.

16. Air Conditioners are not permitted in the rooms. The house is equipped with central air.

17. At their discretion, House Management may enact a Black Out period for any individual(s) that have continuous infractions. Black Out Period will allow the resident to only leave the house to any of the employment or treatment related items found in EMPLOYMENT and TREATMENT EXPECTATIONS. Residents may also attend a 12-step fellowship meeting during blackout with a house supervisor or assistant supervisor only.

18. Lying or cheating the recovery process or house rules will not be tolerated and corrective action up to and including dismissal from the program will occur.

19. Daily Chores must be competed daily between the hours of 7am and 10pm. Chore assignments and completion will be managed by the House Supervisor and Assistant House Supervisors.

20. Weekly Chores must be completed between 8am Saturday and 8pm Sunday. Weekly Chores are more in-depth cleaning responsibilities assigned by the House Supervisors & Asst House Supervisors.

21. Beds are required to be made upon waking. At least pull the blanket over the bed so it looks made, you don't need to get fancy.

22. Smoking is prohibited on the sidewalks in the front or sides of Acceptance House. Smoking is only permitted in the back of the house near the fire escape. You must dispose of the cigarette butts properly in the designated areas. No vaping indoors.

23. Sleeping in any common area or living room is prohibited.

24. There are 11 parking spaces and a 3-car garage. The garage spaces and spots in front of them will be assigned to specific people to avoid blocking people into the garage. If you are not assigned to the spot, do not park in it or in front of it. Of the 11 spaces, only 8 of them will be assigned to residents. The other 3 spaces are reserved for guests. Assignments will be based on first come first serve and tracked on the parking tracker at the house. No one is to park in front of a neighbor’s house or on the street in front of the house. No exceptions. In the very rare circumstance that the lot is full, call the house supervisor or manager for direction. Do Not Park at the Neighbors. Any parking infraction is worth TWO (2) infractions.

25. Residents are not permitted in any bedroom other than their own without permission from the resident(s) residing in that room; they must also be accompanied by the permitting resident.

26. Guests must have over 90 days clean. No guest should be left alone in any part of the building. Guests are only permitted on the 1st floor between the hours of 6pm and 11pm.

 27. No Gambling for any reason or in any way.

28. Curfew is 10pm from Sunday to Thursday and 11pm on Friday and Saturday nights. Infractions for curfew for residents under 30 days are worth TWO (2) infractions each.

29. House quiet time is from 10pm to 6am. Any activity that disturbs another resident's ability to sleep/rest including watching audible videos on a cell phone, is prohibited.

30. The thermostat is only to be adjusted by the house supervisor only.

31. Turn off all lights, appliances, fans, radios, etc. when not in use. Exterior doors and windows must always remain closed except when entering or exiting the building.

32. House meetings will happen bi-weekly; Each Resident must participate in at least 1 house meeting per month.

33. No Loitering - We do NOT want to draw negative attention to the house. You are NOT permitted to sit on the stoop on the front or sides of the building whatsoever or for any reason.

34.Feedback is welcome – Please use the anonymous tip form.

35. Due to COVID19, all residents must attempt social distancing and proper, recommended hygiene to prevent infection spread. If you have any symptoms, you must immediately report them to the house supervisor who will discuss next steps for testing and quarantine efforts. You are required to wear masks in the common areas of the house. You also take full responsibility and liability for your health while living in the house.

36. Residents are not permitted to use the fire escape to enter or exit the house. The fire escape is used for a fire escape only.

37. Please refrain from telephone conversations or any conversations about anything inappropriate immediately outside of the house. This includes the smoking area please. Please respect our neighbors' business models that deal with professional clientele.

38. No deep frying unless using an air fryer.

39. Do not offer to help the neighbors with any type of work. We mow, plow, rake leaves, and so on; free of charge and to build strong bonds with the neighbors. We do this without discussion. Just do it and be careful not to mow over any flowers. Thank you for doing it!

40. The Grievance Form is made available for complaints from residents, family members, and community members at

41. In the event of an Emergency, the Emergency contact will be notified of the location and situation associated with the resident. By signing this agreement and providing their information, you are permitting for those details to be shared. An emergency may include, but is not limited to, an injury, death, relapse, or mental incapacitation.

42. At Uber St, if a resident has a locked room, house management has the right to enter the room at any time. The resident is not permitted to change their locks nor make extra keys. House management will provide a courtesy knock before entry but does not require permission to enter. Regardless of whether a room is locked, residents are not permitted to enter other residents rooms with the exception of a fire emergency.


Infraction Process - At Acceptance House, any time a rule is broken an “infraction” is tracked. Excessive cumulative infractions will result in black out periods, additional chores, or removal from the program as warranted by the infractions.

1. Each infraction type is separate from one another.

2. You cannot earn more than one infraction per type per day.

3. The infraction will be logged in the Infraction Form which will automatically email the Resident

4. In addition to the email, residents will be notified by either text or an in-person conversation.

5. Each infraction will roll off after 60 days.

6. House Supervisors/Asst. Supervisors can be held accountable through an anonymous tip form which will be reviewed by Acceptance Homes LLC Management regularly.



This section describes the processes associated with various emergency situations.

Evacuation & Transfer - If the need for evacuation develops, all residents will meet at the nearest safe location in the parking lot or garage area. Either carpooling or public transportation can be used to transfer to another residence until it is safe to return. Overnight permissions will be granted in cases of emergency.

Assignment of Staff/Volunteer - All management will be on call during emergency situations and readily available including the house owner and all supervisors. A virtual house meeting will be held at various intervals of the day to ensure that open communication is taking place.

Evacuation & Transfer (due to alcohol or drug use) - No resident is forced to leave or drive away from the house due to intoxication. An ambulance can be called at the resident's expense to drive them to the nearest hospital for emergency treatment. If necessary, a doctor or psychologist can also be called for mental evaluation and assessment at the resident's expense.



This section details the rules associated with having a job while living at one of the Acceptance Houses.

1. All residents may work from day 1 of entering Acceptance House; however, this does not excuse the meeting attendance requirements.

2. No resident is permitted to work in a location that is not conducive to recovery such as a bar. Restaurants are acceptable if the resident is not a bartender.

 3. During the first 90 days, the curfew restrictions must be upheld. After 90 days, exceptions must be approved by the House Supervisor.

4.  All residents are required to participate in a minimum of 20 hours of work, community service, or treatment on a weekly basis.

5. Residents must have employment within 45 days of entry at Acceptance Homes and be actively looking for work within the first 30 days unless on social security and unable to work.

6.  While it is acceptable to work "odd jobs" for extra cash, you must have a job that has proof of income and proof of a schedule.

7.  Any overnight schedules must be approved by the House Supervisor along with a Recovery Plan for meeting attendance.


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.


First Name:Client first nameLast Name:Client last name

Today's Date:Date

After submission, please contact the management directly to schedule an interview if you have not already.