**Intake Form**
**Please enter your full name as it appears on your official documents. Ensure that the spelling and format are consistent across all documents.**
**Client Information**
First Name:Client first name
Middle Initial:Text field
Last Name:Client last name
Nickname:Text field
Date of Birth:Client birthdate
Social Security Number:SSN
Gender:Client gender
Preferred Pronoun:Client pronoun
Marital Status:Client marital status
Race:Client race
Phone #:Client phone
Email:Client email
Estimated date of admission
Client admit date
Emergency Contact:
1,First Name:Text field Last Name:Text field
Phone:Text field
2,First Name:Text field Last Name:Text field
Phone:Text field
State License or ID:Dropdown
ID Issuing State:Text field
State ID #:Text field
Do you own a vehicle:Dropdown
Do you have vehicle insurance:Dropdown
**Note: If yes, you will be required to show proof of insurance.**
**Veteran Status**
Client veteran status
**Probation**
Are you on Probation or Parole?:Dropdown
Probation/Parole Officer Name:Text field
Probation/Parole Contact #:Text field
Email:Text field
CDC #:Text field
Page 1
**Medical Information**
Do you have Medical Insurance?:Dropdown
Insurances:Text field
Do you have any chronic medical issues we should be concerned about?(Example: Diabetes, COPD, etc.)
Client health problems
Do you have any issues we should be concerned about?(Example: Anxiety, Mental Disorder, etc.)
Client diagnosis
Client Medical Notes:
Client medical notes
Page 2
**Medical Information**
Do you have any regular medical appointments?:Dropdown
If YES, Please Explain:Paragraph
Do you have any special medical equipment?:Dropdown
If YES, please explain:Paragraph
Do you have any issues with bladder control?:Dropdown
If Yes, or Sometimes Explain:Paragraph
Can you walk independently?:Dropdown
If No, or Sometimes Explain:Paragraph
Can you participate in household cleaning and chores?:Dropdown
If No, or Sometimes Explain:Paragraph
Can you bathe and dress yourself?:Dropdown
If No, or Sometimes Explain:Paragraph
Do you smoke?:Dropdown
List food items that You Do Not like or allergies
(Example:Meats,Vegetables,etc.):
Text field
(List your favorite foods:(Example:Meats,Vegetables,etc.):
Text field
Page 3
**Resident Suitability Questionnaire**
Are you recovering from any addiction that we should be aware of?:Client substances of choice
If YES, please explain:
Text field
Have you attended any supportive meetings?:
Dropdown
If yes, what kind of meetings attended?:
Client kinds of meetings attended
Date of last meeting attended:
Date:Date
List Activities you enjoy doing:Text field
List concerns you may have living with a roommate:Text field
List ANYTHING else we should be concerned about:Text field
**Employment History**
Do you work or volunteer anywhere?:Dropdown
If Yes, please explain work skills or certificates:Text field
Do you have an up-to-date resume?:Dropdown
Page 4
**Licensee Agreement**
Please Initial below:
I understand that THIS AGREEMENT IS NOT A LEASE.
I understand that Harmony Haven Homes, LLC provides and pays for utilities, furnishings, cleaning services, and controls all keys or door codes to the premises and individual rooms.
I understand that if I violate any rules of the licensee agreement, I may be considered a criminal trespasser and subject to arrest under State Penal Code, “Trespassing.”
I understand that sober living homes have broad authority to lien all property contained within the licensee’s room.
I have read and understand the house rules provided to me. (see addendum VIII)
I understand that Harmony Haven Homes, LLC is NOT an assisted living facility or a nursing home and that the LANDLORD & PROPERTY MANAGER DOES NOT provide assistance with activities of daily living, medicine management, bathing, brushing, shaving, cutting food, toileting, transportation, supervision outside of the residence, incontinence care, dressing, movement, or other daily activities. Outsourced third parties may stop by and provide these services to the “licensee” if the “licensee” has a relationship with this outsourced third party; however, under no circumstances does Harmony Haven Homes, LLC provide these services directly.
I understand that rent is $175 per week, payable weekly in advance, with a one-time deposit of $100.
I understand that any damages (other than normal wear) will be my financial responsibility.
I understand that the sober living home operator will have a lien for unpaid fees against all of the licensee's nonexempt personal property that is in the property and may seize such nonexempt property if the licensee fails to pay. Property Code governs the rights and obligations of the parties regarding Harmony Haven Homes, LLC’s lien. Harmony Haven Homes, LLC may collect a charge for packing, removing, or storing property seized in addition to any other amounts Harmony Haven Homes, LLC is entitled to receive. Harmony Haven Homes, LLC may sell or dispose of any seized property in accordance with the provisions of the Property Code.
Any person who is a prevailing party in any legal proceeding brought under or related to the transaction described in this license agreement is entitled to recover a maximum of $500 in attorney’s fees from the non-prevailing party.
Client Initials:Initials Text field
**PEST CONTROL AND INFESTATION**
**Bed Bug Addendum AND Other Infestation:**
A. This addendum addresses situations related to bed bugs and other infestations (roaches, gnats etc.) which may be discovered infesting the dwelling or personal property in the dwelling. You (licensee) understand that we relied on your representations to us in this addendum.
B. **INSPECTION:** You agree that you: Have inspected the dwelling prior to move-in and that you did not observe any evidence of bed bugs, roaches or other infestation.
C. **INFESTATIONS:** Prior to move-in, Licensee is certifying that they have examined the property for bed bugs, rodents and other bug infestations and did not observe any evidence of bed bugs or bed bug infestation or any other infestations including roaches, gnats etc. Therefore, in signing this addendum, Licensee certifies that if bed bugs or other bug infestations are later found in this unit, they will be deemed to have been introduced by the Licensee or one of the Licensee’s guests and that the LICENSEE WILL BE RESPONSIBLE FOR THE PEST TREATMENT, including all reasonable costs of cleaning and pest control treatments. If we must move other residents in order to treat adjoining or neighboring dwellings to your dwelling unit, you will be liable for payment of any lost income and other expenses incurred by us to relocate the residents. If you fail to pay us for any costs you are liable for, you will be in default, and we will have the right to terminate your right of occupancy and exercise all rights and remedies under the license agreement contract. You will be held directly liable and will deal directly with city officials including but not limited to section 8 inspectors, code compliance inspectors, police and probation officers and any other party that deems the unit unclean and infested and will hold Harmony Homes, LLC/property manager harmless for bed bug, roach or other pest infestations.
D. **COOPERATION:** If we confirm the presence or infestation of bed bugs or other bugs or rodents, you must cooperate and coordinate with us and our pest control agents AT YOUR EXPENSE. You must follow all directions from us or our agents to clean and treat the dwelling that is infested. You must remove or destroy personal property that cannot be treated or cleaned as close as possible to the time the dwelling is treated. We have the right to require you to temporarily vacate the dwelling and remove all furniture, clothing and personal belongings in order for us to perform pest control AT YOUR EXPENSE. If you fail to cooperate with us, you will be in default and we will have the right to terminate your right of occupancy and exercise all rights and remedies under the lease contract. YOU ALSO AGREE TO ALLOW US TO EXTERMINATE THESE PESTS IMMEDIATELY UPON DETERMINATION THAT INFESTATION HAS OCCURRED AND THAT YOU WILL REIMBURSE US FOR THIS EXTERMINATION.
E. **PETS:** Animals or pets of any kind are not permitted
on the premises of Harmony Haven Homes properties at any time. This rule excludes service animals that are individually trained to do work or perform tasks for individuals with disabilities, as defined by the Americans with Disabilities Act (ADA). Licensees with service animals must provide appropriate documentation and ensure that their service animal does not pose a direct threat to the health and safety of others.
By initialing at the bottom of this page, I acknowledge that I have read and understood the information provided on this page. I am aware of the policies and procedures outlined here and agree to abide by them during my stay at Harmony Haven Homes.
Client Initials:Initials Text field
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**INDEMNIFICATION**
Please initial below:
I,agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire.
Each party hereby agrees to indemnify the other and the other’s employees, officers, directors, agents, family members and other related parties against all damages for bodily injury, including death, or damage to real or tangible personal property to the extent proximately caused in the course of performing this Agreement
It is my intention and I understand that I am binding myself, my heirs, agents, relatives, executors, administrators, assigns and successors in interest, and understanding this, so hereby expressly release and discharge Harmony Haven Homes, LLC, its agents, owners, landlords, directors, executives, successors, administrators, assigns, affiliates and agents from any claims against Harmony Haven Homes, LLC created or arising out of, or in any way whatsoever related to the service or housing space provided. I hereby waive any claim for damages to persons or property, which may occur as the result of the use of the said premises. This waiver includes any negligent acts or omissions caused directly or indirectly by Harmony Haven Homes, LLC Cooperative Living or the owners of said Property, including its officers, directors, or employees and understand that my claims, which may in the future arise out of personal injuries, accident, death, hurricanes, tornadoes, rain, fire or other acts of God to the residence, myself or damage to my property of any kind, are hereby waived.
I,and any and all family, relatives, attorneys, assignees and any others acting on my behalf hereby further agree to indemnify and hold harmless Harmony Haven Homes, LLC Cooperative Living, its owners, representatives, agents or Owners of said Property, including its officers, directors, or employees, from any claims or damages, which may occur to the undersigned licensee or to any child, invitee, or guest of the undersigned.
It is understood and agreed that this agreement includes, but is not limited to, injuries occurring due to: slipping and falling on any surfaces wet or dry, transportation to and from the premises or any other location, fires, sprained or broken limbs, cuts, abrasions, eye injuries, bacterial infections, death, fights, drowning, riots, stabbings, tornados, hurricanes, floods, hail storms, acts of terrorism and any other acts of God, accidents or injuries on the property or off the property.
Licensee assumes all risk of harm resulting from the use of any pools, trampolines, or recreational facilities on Harmony Haven Homes, LLC property and waives all claims against the Harmony Haven Homes, LLC arising from or relating to the use of said facilities or the participation in such activities and programs by Licensee and his or her guests, even if caused by the Harmony Haven Homes LLC’s negligence or gross negligence. The use of said facilities shall be at the sole risk of Licensee and his or her guests.
Each party agrees to indemnify and hold harmless the other party and its employees, members, landlord, successors, attorneys, family members, agents and assigns, from any claims, liabilities, losses, damages, and expenses asserted against the other party and arising out of the indemnifying party’s negligence, willful misconduct, and negligent performance of, or failure to perform, any of its duties or obligations under this Agreement. The provisions of this indemnification are solely for the benefit of the parties hereto and not intended to create or grant any rights, contractual or otherwise, to another person or entit
Licensee will indemnify and hold harmless Harmony Haven Homes, LLC, its agents, owners, directors and officers against all liability, including liability arising from death or injury to person or property during the term of this agreement, and any renewal or extension thereof, caused by any act or omission of the Tenant, or the family, guests, agents or employees of the Tenant. Tenant will indemnify and save Landlord harmless from all liability, damage or expense incurred by Landlord as a result of death or injury to persons or damage to property (including the Premises) where this Lease Agreement required the Tenant to procure insurance for said liability, damage or expense and Tenant failed to do so.
Harmony Haven Homes, LLC, its agents, owners, directors and officers shall not be liable for any damage or loss to person or property caused by other licensees or other persons, or caused by theft, vandalism, fire, water, smoke, explosions or other causes unless the same arises solely from the omission, fault, negligence or other misconduct of Harmony Haven Homes, LLC. Failure or delay in enforcing Lease covenants of other Tenants shall not be deemed to be negligence, omission, fault or other misconduct.
Licensee acknowledges that security cameras are used at our facilities to ensure the security of the premises from theft, unauthorized access, or damage to the property. All security cameras record both video and audio, and are strategically positioned so as to not interfere with the peaceful possession of our residents or their privacy. Licensee accepts the monitoring of interior living spaces and exterior spaces by security camera, and agrees not to tamper with the security cameras.
By initialing at the bottom of this page, I acknowledge that I have read and understood the information provided on this page. I am aware of the policies and procedures outlined here and agree to abide by them during my stay at Harmony Haven Homes.
Client Initials:Initials Text field
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**RULES**
Please initial below
I,am aware that I maybe fined and or discharged from the property for violation of house rules/destruction of property.
I,am required to notify House Leader of Harmony Haven Homes, LLC a minimum of thirty days prior to vacating the premises.
My payment (in full) on Friday each week & no later than Monday at 10:00 p.m. of each week of the month via a third-party representative payee or autopay.
I,understand that upon leaving a Harmony Haven Homes, LLC location by my will or as a result from rule infractions I will not be eligible for a refund.
I,understand that this agreement is not a lease. Licensee holder may give a minimum of 30-day notice to vacate and receive deposit and prorated refunds. Any damages by licensee will be the financial responsibility of the licensee and may be withdrawn from the refunds. Management of Harmony Haven Homes, LLC Cooperative Living may terminate this licensee agreement at any time. Violation of house rules may result in fines or my dismissal from the property. Threats or acts of physical violence against other licensees or management will result in immediate termination of this license and may result in filing of criminal charges.
I,understand that “vacating” the premises is defined as ALL of my belongings and myself leaving the property.
I,understand that some of the food used is sourced from the community. Licensees are expected to participate in these resources
Harmony Haven Homes, LLC reserves the right to relocate licensees to our other cooperatives at our discretion. Any costs associated with change of address or inconveniences caused by relocation are the sole responsibility of the licensee.
Management / Staff of Harmony Haven Homes, LLC may ask me to provide a urine sample when:
- Erratic or other behavior typical of a person under the influence of alcohol or illegal drugs is observed
- Drug / Alcohol paraphernalia is found on my or in my possession
- Randomly
Please initial below
Under no circumstances are drugs, alcohol or other “non-prescribed” medication allowed in the property. I understand that if I have been found to be using or in possession of any of the above items, I will immediately be in violation of this agreement and will be asked to vacate the unit immediately.
**PROPERTY MAINTENANCE**
A. Licensee’s General Responsibilities: Licensee, at Licensee’s expense, must:
(1) Keep the Property clean and sanitary;
(2) Promptly dispose of all garbage in appropriate receptacles;
(3) Take action to promptly eliminate any dangerous condition on the Property and/or room;
(4) Certify that they will perform all activities of daily living without the help or assistance of any Harmony Haven Homes, LLC representative such as showering, taking medications, shaving, cutting and preparing food, toileting, transportation, dressing and any other activity performed on a daily basis.Food and drinks (except water) are not allowed upstairs. All personal food must be labeled.
(5) Certify that they have inspected their room and that the room is clean and well-maintained.
(6)Prohibited Items Firearms, weapons, personal refrigerators, microwaves, coffee pots, candles, and excessive personal property are not allowed.
By initialing at the bottom of this page, I confirm that I have read and comprehended the information presented on this page. I understand the expectations and guidelines described and agree to adhere to them as a resident of Harmony Haven Homes.
Client Initials:Initials Text field
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**Curfew and Visitation Policy, Overnight Request**
The purpose of this policy is to maintain a safe, structured, and supportive environment for all residents of Harmony Haven Homes.
**Curfew Accountability Policy**
Residents are required to be on the premises and settled in their rooms by 12:00 AM (midnight) unless prior arrangements have been made and approved by the management.
Restricted residents must observe a 10:00 PM curfew, while non-restricted residents must return by midnight.
All residents must sign in and out using the Accountability Board. Residents may also be required to use tracking apps like Life360 or One-Step.
**Late Stay Request:**
Residents needing to stay up past curfew must submit a written request to the management at least 24 hours in advance. Requests will be considered based on individual circumstances.
**Consequences:**
Failure to adhere to the curfew policy without prior approval may result in disciplinary action, including but not limited to a warning, loss of privileges, or termination of residency.Violators will be required to take a drug test upon return, with a $25 fee.
**Exceptions:**
Exceptions to the curfew policy may be granted in cases of employment, education, or other essential activities. Residents must provide documentation to support their request for an exception.
**Termination of Visitation & Overnight Request:**
I,understand for whatever reason cannot comply with these guidelines may result in the revocation of visitor/overnight pass privileges. Staff reserves the right to terminate any visitation that violates the rules or disrupts the environment of Harmony Haven Homes.
Each resident may submit a list of up to four approved visitors, including full names and identification details. Exceptions are made for minor child visitations.Visitors are permitted only in common areas and during designated hours.
**Visitor Check-in:**
All visitors must check-in with staff upon arrival. Visitors are required to show a valid ID. Visitors' IDs will be photographed and documented.
**Guest Restrictions**
Residents are not allowed to host guests overnight or in private rooms to ensure safety and privacy for all.
**Visitation Hours:**
Visitation hours are limited to Fridays, Saturdays, and Sundays, from 4:00 PM to 10:00 PM.
**Scheduling:**
All visits must be scheduled in advance with the management. Visitors must check-in upon arrival, present a state-issued identification, and sign in.
**Number of Visitors:**
Each client may have up to two visitors at a time, unless otherwise approved by the management. Only two clients are permitted to have guests at any given time. All clients will be given a (visitor's list) which must be filled out. You can find the "visitors list" at the bottom of this application. If for any reason not filled out the client would not be able to schedule visitors. The maximum visitor amount is currently four and is subject to change.
**Behavior:**
Visitors are expected to respect the rules and guidelines of Harmony Haven Homes. Disruptive behavior will not be tolerated.
**Restricted Items:**
Visitors are not permitted to bring alcohol, drugs, or other prohibited substances onto the premises.
**Children:**
Residents may have children visit, but they must be always supervised.
**Meetings & Checking Policy**
All residents are required to check in daily for meetings, work, or home. This check-in is necessary and mandatory as it provides a solid record of your good habits. It has been proven to help tremendously with the courts and parole officers. Please comply or there will be the loss of privileges, including but not limited to overnight passes and visitor privileges.
Additionally, all residents are expected to attend meetings as scheduled. Meetings are an important part of your recovery and your overall well-being. The success rate of any client and their community is amplified greatly when a minimum of 3 meetings per week are attended. Because of this, these meetings are mandatory. Should you be unable to attend meetings without a valid reason the consequences can be devastating including loss of privileges or worse, loss of sobriety. There are multiple meetings available, including online. Please consult the local listing. We understand that there may be circumstances that prevent you from attending meetings or checking in as required. If you have a legitimate reason for missing a meeting or check-in, please communicate this to management as soon as possible.
Thank you for your cooperation in making Harmony Haven Homes a supportive and accountable community.
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LICENSEE FEES AND PAYMENT TERMS
The weekly rent rate is $150, with a one-time admission fee of $100, making the total admission cost $250. With the first payment of $150, it will be credited as a week ahead. This rate reflects our commitment to making housing affordable and supportive for your journey.
LICENSEE FEES AND PAYMENT TERMS
1. Weekly License Fee: $175, due every Friday by 10pm CST.
2. Monthly License Option: $700 per month, due on or before the first Friday of the month. A one-time admission fee of $100 is required at the time of move-in, making the total due at admission $700.
3. After the first month, the monthly license fee will remain $700 unless staff decides on a different payment arrangement.
LATE PAYMENT POLICY
1. Weekly Payments: If the payment is not received by 10pm on Friday, a late fee of $25 will be applied, making the total due $175 for that week.
2. Monthly Payments: If the monthly payment is late, a late fee of $25 per week will be added to the total. For example, if the payment is four weeks late, the total amount due will increase to $700 for that month.
Examples:
1.Weekly Payment: Steve has been making his weekly payments on time for two weeks but is late with his third payment. He now owes $175 rent plus the $25 late fee, totaling $175 for the week.
2.Monthly Payment: Maria selects the monthly payment option. At admission, she pays $700 ($700 rent plus the $100 one-time admission fee). For subsequent months, Maria owes $700 per month. If she misses the agreed-upon deadline for the next month, she will incur $25 per week in late fees. If four weeks pass before payment, she owes an additional $100 in late fees, making her total $800 for that month.
ADDITIONAL TERMS
1. Licensees not up-to-date with payments will not be allowed overnight passes or visitors.
2. If you are experiencing difficulties with payments, it is your responsibility to inform staff and discuss possible arrangements.
3. Payments are non-refundable, and failure to pay may result in the termination of this license agreement and removal from the premises as per applicable laws.
Clients that are unfortunately not up-to-date with payments will not be able to schedule overnight passes or have visitors. This policy is designed to encourage timely rent payments and ensure that all clients are in good standing. We understand that circumstances may arise, and if you are experiencing difficulties with rent payments, please contact us to discuss possible arrangements. We are here to support you and help you maintain your housing stability.
**RESPONSIBILITIES OF LICENSEE, LICENSEE’S REPRESENTATIVE AND/OR LEGAL REPRESENTATIVE**
You, your representative and/or legal representative, to the extent specified in this agreement, are responsible for the following:
1. Payment of the weekly/Monthly fees.
2. Supply of personal clothing, activities of daily living, medicine, medicine management and other normal day-to-day items and tasks including but not limited to doctor visits, transportation, case management and social worker appointment meetings and scheduling’s.
LICENSEE,LICENSEE’S REPRESENTATIVE AND/OR LEGAL REPRESENTATIVE
By Initial below, I acknowledge that I have read, understood, and agree to the terms outlined in this license agreement. I understand this is NOT a lease and that Harmony Haven Homes retains full control over the premises. I also understand my payment obligations, including late fees and the consequences of non-payment.
Initials BELOW
Initials Text field
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**House Rules Addendum (This is Posted Inside Each Home)**
**House Rules**
Break these rules and your stay will be terminated. You have 3 warnings ONLY (RED TYPE = IMMEDIATE REMOVAL FROM HOME)
1. **SAFETY:**
- No loitering or hanging out in the front yard for any reason. The back patio is used for this.
- Keep entry and exit doors closed and locked at all times.
- Firearms, weapons, personal refrigerators, microwaves, coffee pots, candles, and excessive personal property are not allowed.
- Do not leave items on the floor that may cause a slipping or trip hazard.
- If you spill anything on the floor immediately wipe it up and then place a wet floor sign.
- In case of an emergency, we need all residents to sign in and out of the home when leaving the property.
2. **GENERAL:**
- Do not steal or use another person’s items without permission.
- Do not open or enter any cabinets or closets with locks.
- Turn lights off when not in use.
-The internet is provided but may not be used for viewing pornography or engaging in abusive activities.
-Movies, TV, or music with explicit content (e.g., graphic violence, heavy alcohol use, or strong language) are not allowed.
- You may NOT enter another resident's room at any time.
- Keep room door closed at all times.
- Clothes must be worn outside of your room.
- Never leave personal items unattended in common areas of the home.
- Kitchen closes at 8pm.
- Residents can enter the home during these hours ONLY:
- 6AM-11PM Sunday – Thursday, 12am TV off
- 6AM – 12AM Friday and Saturday, 12am TV off
- 24-hour prior written notice must be given for any & all exceptions
- If 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.
-Household chores are assigned on a rotating schedule and must be completed as directed.
3. **SMOKING, ALCOHOL, AND DRUGS:**
- Smoking is allowed only in designated outdoor areas. Smoking indoors will result in immediate discharge.
-No Alcohol consumption or storage of alcohol in or around premises.
- Do not share medication.
- No storage or use of illegal drugs or unprescribed medication allowed.
- Everyone is subject to random UA.
-Residents must practice total abstinence from mind-altering substances, including legal substances such as Kratom, Delta-8, bath salts, and designer drugs
-Any suspicion of drug or alcohol use must be reported anonymously to leadership, who will take action, including requiring testing or removal from the premises.
4. **CLEANLINESS:**
- Put trash in the trash can, put dirty dishes in the sink, clean up after you use the bathroom.
- Your room shall be kept in an orderly and sanitary condition at ALL times.
- Food is only to be consumed in the kitchen.
- Food is NOT ALLOWED in bedrooms at any time.
- If you spill anything or make a mess anywhere in the house including your room you will be responsible for cleaning it up.
5. **YOUR ROOM:**
- You may NOT enter another resident's room at any time.
- Mattress covers must NEVER be removed.
- Keep room door closed at all times.
- Keep personal items inside of your room. (Valuable Items should be secured)
- All rooms are subject to search by Harmony Haven Homes staff.
6. **PERSONAL HYGIENE**
- Diapers, bed pads, or any personal hygiene items must be disposed of properly.
- You shall keep up with your personal hygiene by bathing and brushing your teeth frequently.
- You shall have no complaints that you or your personal space has offensive odors.
7. **BEHAVIOR:**
- No aggressive or violent behavior EVER!
- No profanity or offensive language directed at any residents, neighbors, or Harmony Haven Homes staff or helpers.
- No lending or borrowing money, cars or other property from other residents or neighbors.
- All residents must attend outpatient treatment.
- No romantic advances on Harmony Haven Homes staff.
-Romantic or intimate relationships between residents are strictly prohibited.
-Verbal or physical violence towards residents or staff is grounds for immediate discharge.
-Residents must be respectful and courteous to neighbors, staff, and other residents.
-Borrowing money, cigarettes, food, or clothing from others is not allowed.
-Residents are on a three-week restriction period to focus on employment, recovery, and obtaining necessary documents (e.g., identification, health insurance).
-Residents must secure employment within two weeks of joining the program.
-An individualized action plan must be developed within 48 hours of joining the program, outlining personal goals and needs.
8. **LAUNDRY:**
- Use of Laundry on scheduled day and time ONLY.
- Laundry area must be clean.
- You may not wash another person’s clothes.
- You may not put feces soiled items into any washer or dryer in the home.
9. **Damage and Theft**
Intentional damage to property will result in immediate discharge and may be reported to law enforcement.
Theft will result in immediate discharge, with no exceptions.
-HHH is not responsible for loss or theft of personal belongings. Lockboxes are recommended for storing valuables.
- A $20 fee will be charged if HHH must pack and store abandoned belongings, which will be donated after seven days.
Additional Guidelines
10. **Vehicles**
-Residents are allowed one insured and registered vehicle in good working condition. Vehicle maintenance on the property is prohibited.
**Open-Door Policy**
-HHH has an open-door policy with law enforcement, probation officers, and other court-related personnel. Residents must be respectful to visiting authorities.
I,Initials Text field have read and understand what I can and cannot do while living in Harmony Haven Home. I understand and agree that if I break any rules within this document in red type, my stay will be terminated immediately, and I will be banned from living in other homes that Harmony Haven Homes manages.
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**Visitors list:**
1# Visitor
First Name:Text field
last Name:Text field
Visitor relationship with client:
Dropdown
2#Visitor
First Name:Text field
Last Name:Text field
Visitor relationship with client:
Dropdown
3#Visitor
First Name:Text field
Last Name:Text field
Visitor relationship with client:
Dropdown
4#Visitor
First Name:Text field
Last Name:Text field
Visitor relationship with client:
Dropdown
**Please note: Guests must show ID upon arrival. Thank you for your cooperation.**
**Please note: visitor amount is currently four and is subject to change.**
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**AGREEMENT AUTHORIZATION**
Thank you for your cooperation. Your feedback helps us to improve our services and support our clients better.
The information I have provided above is true and accurate to the best of my knowledge. I understand that if I have not provided true and accurate information that it will be grounds for eviction.
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.
We, the undersigned, have read this Licensee Agreement and agree to abide by the terms and conditions.
**One Step App Requirement**
I,Initials Text field fieldhereby agree to download the One Step Mobile App and have my location settings set to "Always On". If I change the location settings for the App to "Only When Using" or "Never" without explicit Staff permission, I will face disciplinary action or possible discharge from the facility. If I experience issues with the app, specifically pertaining to the check-ins and location tracking, I must alert staff members immediately so they can resolve any glitches to continue monitoring my location and meeting attendance.
**RESPONSIBILITIES OF LICENSEE, LICENSEE’S REPRESENTATIVE AND/OR LEGAL REPRESENTATIVE**
You, your representative and/or legal representative, to the extent specified in this agreement, are responsible for the following:
1. Payment of the weekly fees.
2. Supply of personal clothing, activities of daily living, medicine, medicine management and other normal day-to-day items and tasks including but not limited to doctor visits, transportation, case management and social worker appointment meetings and scheduling’s.
**The licensee, licensee’s representative and/or licensee’s legal representative agree to the Resident Terms & FEES**
licensee’s representative and/or licensee’s legal representative Only
Signature
DATE:Date
**(Signature of Licensee/Client Only)**
Signature
Date:Date
After completing your information, please click "Submit Form" at the bottom right.
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