CLIENT INTAKE FORM
Thank you for choosing Rocky Mountain Sober Living
Rocky Mountain Men's Sober Living homes offer a structured, supportive environment for individuals seeking recovery. Our goal is to provide an affordable sober living facility to those who want to overcome their addictions and pursue a new, healthier lifestyle—free from alcohol and chemical dependency. We offer a place to feel human again, establish a disciplined life, and regain and maintain a robust recovery program while experiencing the relational support necessary to sustain a sober existence.
Minimum Requirements
1. Have a valid Driver's License or State ID.
2. Have either a Social Security card or a Birth Certificate.
Application Process
1. Complete the online application.
2. Call and complete a phone interview with RMSL staff.
3. If successful, arrange an in-person Interview with the house manager and fellow peers in the house you are interviewing for.
4. Arrange to meet our RMSL intake specialist.
WHAT WE OFFER:
Rocky Mountain Sober Living LLC provides recovery-related activities and access to Coaching Services where individuals can continue working on living skills, developing relationships in the recovery community, and maintaining sobriety while reintegrating into the workforce and community. Members are held to high standards, promoting growth, accountability, and personal development in recovery.
What you are responsible for: Members provide food, hygiene products, clothing, and any personal items they wish to decorate the rooms with (Must Be Approved By RMSL). Rocky Mountain Sober Living LLC will provide all bedding, pillows, cleaning products, and common household cleaning items.
Residence at Rocky Mountain Sober Living LLC requires actively working in a recovery program, being a positive member of our community, maintaining abstinence from all drugs and alcohol, and following all house rules, including abiding by curfew requirements.
Please fill out this short application, and we will contact you soon.
First name* Client first name - Client last name
Phone Number* Client phone Email Address*Client email
Date of Birth* Client birthdate Social Security #: SSN
Gender* Dropdown
Which Race or Ethnicity most closely describes you?* Dropdown
Current Personal Address:Client Address
City Client City: State Client State Zip Code: Client Zip
Do you have a Valid driver's License or State ID?: DropdownExpiration Date? Date
Do you have a Valid Social Security Card or Birth Certificate? Dropdown
What is the best way to contact you?* Dropdown
Current Marital Status* Dropdown
Number of years married:Text field
Are You On Medicaly Assisted Treatment? Dropdown
Are You Using Methadone? Dropdown
Are you currently or have been homeless in the last year?* Dropdown
How did you hear about us, or who referred you?*Text field
Are you currently employed?* Dropdown
Employer Name? Text field Employer Phone: Text field
Have you ever been a resident of Rocky Mountain Sober Living before?* Dropdown
Have you ever been diagnosed with Bipolar or with schizophrenia? Dropdown
In a few sentences, please describe your Mental Health History and current Mental Health situation? *
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Are there any issues (physical or mental) that would prevent you from being able to live in a community living environment?* Dropdown
Admission Guidelines:
• Minimum 18yrs of age
• Must be sober upon admission
• Able to fulfill financial obligations
• Be able/willing to work, attend school, or volunteer full-time (or any combination thereof)
• Willing to participate in Rocky Mountain Sober Living LLC’s Program
• You must leave the facility by 8 a.m. and not return until 5 p.m. daily. Unless volunteering 20 hours a week.
I acknowledge I have read and understand all provisions of this agreement:
Printed Name: Text field
Date:Date
Signature:
Signature
MEDICAL INFORMATION
Insurance Provider: *Text field
Member ID: *Text field
Group Number: *Text field
Relationship to the Insured Subscriber: *Text field
Medications:
Please BRING ALL MEDICATION BOTTLES, including supplements, to your intake with RMSL.
Knowing the names and dosages of your current medications is VERY IMPORTANT.
Medications:
Please list any medications and dosages you currently take (including over-the-counter medications, herbals, and any nutritional supplements).
Medication
List Any Additional Medications and Dosages here:
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RISK ASSESSMENT (check appropriate boxes):
1. Have you been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor):*
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2. Have you ever been hospitalized for mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, Schizophrenia, anxiety, drug or alcohol problems, etc.)*
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3. Has anyone in your family had mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, drug or alcohol problems, etc)*
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4. Have you ever been referred to Social Services?*
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5. Been so distressed you seriously wished to end your life? *
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6. Have you had or do you have:
a. A specific plan for how you would kill yourself? *
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b. Access to weapons/means of hurting yourself? *
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c. Made a serious suicide attempt? *
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d. Purposely done something to hurt yourself? *
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e. Heard voices telling you to hurt yourself? *
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7. Had relatives who attempted or committed suicide? *
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8. Had thoughts of killing or seriously hurting someone? *
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9. Heard voices telling you to hurt others? *
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10. Hurt someone or destroyed property on purpose? *
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11. Slapped, kicked, or punched someone with intent to harm? *
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12. Been arrested or detained for violent behavior? *
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12. Been to jail for any reason? *
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13. Been on probation for any reason? *
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What do you consider to be the top three stresses in your life?
1. *Text field
2. *Text field
3. *Text field
Mental Health History
1. Have you been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor):*
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2. Have you ever been hospitalized for mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, Schizophrenia, anxiety, drug or alcohol problems, etc.)*
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3. Has anyone in your family had mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, drug or alcohol problems, etc)*
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4. Have you ever been referred to Social Services?*
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Drugs and Alcohol Use:
Sobriety BirthDate: Date
Do you or did you:
1.) Regularly use Drugs and alcohol (more than twice per month)?
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2. Had trouble (legal, work, family) because of your addiction?
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3.) Felt you should cut down on your addiction?
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4.) Been annoyed by people criticizing your addiction?
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5.) Felt bad or guilty about your addiction?
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6.) Ever had a drink or a drug first thing in the morning?
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Goals for Sober Living:
What are your goals for treatment? In other words, what things would you like to see change or be different about yourself? *
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LEGAL
If you are currently in a program or incarcerated, please describe where, your estimated exit date, and who to contact regarding your application?*
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Please describe your current legal situation?*
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If you are currently on Parole/Probation, please tell us your DOC#Text field
If you are currently on Parole/Probation, please provide us with the county and the name and number of your Parole/Probation officer.*
Name: Text field
County: Text field
Phone Number:Text field
Are you required to register as a sex offender?*
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Have you ever been convicted of felony child abuse or neglect; spousal abuse; a crime against children (including child pornography); or a crime involving violence, including rape, sexual assault, or homicide but not including other types of physical assault or battery?
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Have you ever been convicted of a felony for physical assault, battery, or a drug-related offense within the past five years?
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Have you ever been convicted of arson or arson-related charges?*
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Have you ever been convicted of Murder or Attempted Murder?
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Membership Dues and Financial Policy
Rocky Mountain Sober Living LLC
1. Membership Dues
Self-Pay Sliding Scale:
Daily prorated dues: $25.00/day
Monthly membership dues: $725.00
Discount: If dues are paid on the due date, the fee is reduced to $600.00 plus a 3% processing fee.
A non-refundable $150.00 intake fee is required upon move-in.
2. Payment Schedule
Dues are collected monthly on the same day of the month you moved in. For example, if you moved in on the 10th, subsequent dues will be billed on the 10th of each month.
Members must pay dues for the upcoming month (not retroactively).
3. Non-compliance and Late Payments
Late payments are subject to:
Accounts more than three days delinquent will result in:
Will be put on Level Zero
Visitor or guest limitations.
Program probation, restrictions, or discharge.
4. Non-Refundable Policy
Membership dues, intake fees, and bed reservation fees are non-refundable under any circumstances, including discharge or voluntary exit.
Dues will not be prorated for the final week of discharge.
5. Payment Methods
Payments must be made via money order, cashier’s check, debit, or credit card.
Cash is not accepted.
6. Bed Reservations
A $150 non-refundable fee plus a 3% processing fee is required to reserve a bed.
Reservations are valid for up to seven days.
7. Delinquent Accounts
Members who fail to comply with payment arrangements may have their accounts sent to collections.
Restrictions will apply to delinquent accounts, including those placed at level zero, guest limitations, or membership termination.
8. Account Inquiries
For account questions, please contact accounts receivable at (719) 377-2067.
Acknowledgment
By signing this agreement, members acknowledge that all fees are final, non-refundable, and fully payable as outlined above. Members are responsible for ensuring timely payments to avoid restrictions or additional penalties.
Prices are subject to change with advance notice.
Printed name: Text field
Sign: Signature
Date: Date
1. House Expectations
* Peer Respect: Residents must respect fellow housemates and staff.
* House Cleanliness: Residents must clean their areas and participate in assigned chores.
* Curfew & Accountability: When leaving the property, please follow the designated curfew and let staff know your whereabouts for accountability and safety.
* Abstinence: Residents must refrain from alcohol and drug use.
2. Required Meetings and Coaching
*Peer Coaching Groups:
*Frequency: Each resident must attend two weekly in-house peer coaching group sessions.
*Participation: Active engagement in group discussions and respect for shared experiences are expected.
*One-on-One Peer Coaching:
*Frequency: Each resident must attend a weekly meeting with a peer coach.
*Preparation: Residents should prepare personal goals or topics to discuss and reflect on their recovery progress.
3. Outside Recovery-Related Activities
Time Requirement: Residents must complete at least 3 hours of recovery-related activities outside the house weekly.
Examples of Approved Activities:
*12-Step meetings (AA, NA, etc.)
*SMART Recovery meetings
*Therapy sessions with a licensed counselor
*Participation in recovery workshops or seminars
*Documentation: Residents must post their outside hours in the WhatsApp group
4. Additional Recovery Requirements
Progress Review: Weekly review with house staff or peer coach to assess personal goals and recovery journey.
Goal Setting: Each resident is encouraged to set weekly goals in alignment with their recovery plan, which will be reviewed during peer coaching sessions.
Sponsorship Requirement: Residents are encouraged to work with a sponsor to strengthen accountability.
5. Consequences for Non-Compliance
Missed Meetings or Sessions: Unexcused absences from required meetings, one-on-ones, or outside activities will result in a warning. Repeated absences will prompt further discussion with staff and could impact residency status.
Substance Use: Any instance of substance use or evidence of a relapse will be addressed with an immediate review and possible escalation, up to termination from the program if necessary.
Behavioral Issues: Disruptive behavior may result in a suspension of privileges or further disciplinary action.
LEVEL PROGRAM
Rocky Mountain Sober Living operates on a phased program. This allows you to be in control of your recovery journey. Below is our phase program and what is required to complete each phase. Phase graduation is based on compliance with all Rocky Mountain Sober Living rules and regulations. You may only phase up by being current on all money owed.
Level One rules/requirements:
1. Attend initial intake and complete the following.
a. Meet with RMSL intake/peer coach.
b. Complete Narcan Test.
c. Do intake for Medical Check up.
d. Do Reliatrax Intake.
2. 8 pm curfew 7 Days a week
3. 8 hours of Recovery Groups weekly- this piece is five with a coach and three outside the house.
4. Weekly attendance of a home group.
5. Establish full-time employment.
6. Acquire a bank account.
7. No Overnights.
When residents have demonstrated that they have established good habits by showing that they have been working a recovery program, are currently on dues, have a job, have completed U.A. intake, and have a sponsor, then they can progress to Level Two.
Level Two rules/requirements:
1. 11pm weekdays/1 am weekends curfew
2. 6 hours meetings per week- five with the coach and one outside the house
3. Continue attending Rocky Mountain Sober Living Community Groups.
4. 2 Overnight/week (pre-approved)
Level Three requirements:
Level Three residents are expected to take on a leader and mentor role in the program.
and will be discussed once they have shown progress in all areas of their recovery.
Level ZERO:
Level zero is a punitive level.
1. 8 pm curfew
2. Daily meetings
3. Only can go to work or recovery-related events
4. Complete 1 hour/day of supervised volunteer work at the house
I have read and understand the Phase Program above.
Signature.
Signature
Date:
Date
The Rules:
Testing Policy – (UA’s / Breathalyzer
Zero-Tolerance: Rocky Mountain Sober Living LLC has a strict policy regarding the use of drugs and/or alcohol (This includes Marijuana or any form of THC-based CBD products, as well as Kratom, Kombucha, and Alcohol-Based Mouthwashes). Any use of these substances and/or contraband/paraphernalia found on premises will result in immediate action up to and including, but not limited to, non-compliance restriction and/or immediate discharge. Members with knowledge of other Members using and failing to inform staff will be subject to identical/similar action. “There are no False Positive test results”. All Test Results are valid; no excuses will be accepted.
Sobriety Monitoring: Members are subject to mandatory random urinalysis and breathalyzer screening. Rocky Mountain Sober Living uses Genesis Reference Labs for once-a-week drug screenings. Additionally, 1-2 instant UAs are given at the staff/house manager’s discretion or as often as necessary. The test administrator witnesses all UAs to ensure compliance. The member will be given 30 minutes from being asked to produce urinalysis. Upon being asked for a breathalyzer, the member must submit it immediately. Should the member fail to meet these guidelines or refuse any test, immediate action will be taken, up to and including but not limited to the cancellation of the membership and immediate discharge.
Members can expect to have their belongings checked within the house and any mode of transportation they use. If a search is refused, immediate action will be taken, up to and including, but not limited to, the cancellation of the membership and immediate discharge.
Physical or verbal abuse acts, threats of violence, and hostile behaviors WILL NOT be tolerated. Immediate action will be taken, including but not limited to behavioral contracts; immediate action will be taken, up to and including but not limited to the cancellation of the membership and immediate discharge.
Members are NOT permitted to remain on the property if they are found to be under the influence or test positive for any prohibited substance. In the event of a relapse, the situation will be handled case-by-case. Members will be offered a ride to detox or hospital by staff. Staff will not take Members to an unknown/unsafe location. If a member refuses detox/hospital, the member will be allowed 30 minutes (with staff/house manager supervision) to find a ride away from the property. If a ride is not obtained, further action may be taken, including but not limited to contacting local law enforcement. If a member attempts to operate a vehicle at this time, local law enforcement will be contacted immediately.
Medications: If a member is taking any medications (prescription or over the counter), these will be REQUIRED to be kept in their personal bedside safe that is located onsite at all times. Under no circumstances may a member share or distribute their medications to any other member. Medications must remain in your safe at all times. Storage of medications anywhere else on the property is grounds for termination of the client's membership.
Medication-assisted treatment (MAT)
Rocky Mountain Sober Living prioritizes the safety and well-being of all residents. We recognize the importance of medication management in maintaining sobriety and overall health. Clients must securely store all prescription and over-the-counter medications in personal safes provided by our homes. Only clients are granted access to their designated safes. Staff members are available to assist with the safekeeping and monitoring of medications as needed. Any concerns or changes in medication must be promptly communicated to staff for support and guidance. This policy ensures accountability, minimizes risks, and promotes a supportive environment conducive to recovery.
RMSL does allow MAT. Your regiment must be doctor-prescribed. Just to let you know, RMSL does lab tests and monitors your medication levels. If you are a methadone user, you must visit the local clinic to administer your dose. Medications must remain in your locker at all times. Storage of medications anywhere else on the property is grounds for termination from the program.
Rocky Mountain Sober Living LLC does NOT assume any responsibility for lost or stolen medications. Should there be a medication issue, Rocky Mountain Sober Living LLC will investigate the matter as seen fit and WILL NOT reimburse a member for any associated costs. Rocky Mountain Sober Living LLC staff can conduct medication counts anytime.
Regarding Suboxone, Members on this medication will agree to regular and random medication counts conducted by Rocky Mountain Sober Living LLC staff (or house manager). Should any discrepancy (over or under) occur in the counts, the member will be subject to immediate action, including but not limited to the cancelation of the membership and immediate discharge.
Regarding methadone usage. RMSL requires that you receive your daily dose of Methadone from the local clinic. Storage of Methadone on the site is prohibited.
Required Meetings and Coaching
Peer Coaching Groups:
Frequency: Each resident must attend two weekly in-house peer coaching group sessions.
Participation: Active engagement in group discussions and respect for shared experiences are expected.
One-on-One Peer Coaching:
Frequency: Each resident must attend a weekly meeting with a peer coach.
Preparation: Residents should prepare personal goals or topics to discuss and reflect on their recovery progress.
Outside Recovery-Related Activities
Time Requirement: Residents must complete at least 3 hours of recovery-related activities outside the house weekly.
Examples of Approved Activities:
12-Step meetings (AA, NA, etc.)
SMART Recovery meetings
Therapy sessions with a licensed counselor
Participation in recovery workshops or seminars
Personal Property/Money:
Rocky Mountain Sober Living LLC is not responsible for lost, stolen, or damaged personal property. Members are responsible for safeguarding their belongings, including money and valuables. Staff may search members' property, including vehicles, at any time. Any personal property left behind after discharge will be donated or discarded after 7 days.
Personal Vehicles:
Members may have one vehicle on the property. If it becomes inoperable, it must be removed within 72 hours, or it will be towed at the owner's expense.
Employment/Volunteering:
Within two weeks of admittance, members must secure and maintain at least 30 hours per week of employment, volunteering, or school. If not working full-time, members must leave the facility between 8 am and 5 pm, returning only for a 30-minute lunch. Proof of hours worked is required for the first four weeks.
WhatsApp Requirement:
Members must download WhatsApp for communication regarding UAs and important updates. Required groups include the House Group, RMSL Main Group, and Recovery Activity Group.
Overnights:
Overnights are allowed based on the member’s phase with 24-hour notice. For multiple consecutive overnights, 48-hour notice is required. Vacations or extended trips require two weeks' notice and staff approval. Overnight requests must be made via the Overnight QR code. Members must attend all required meetings/activities before going overnight.
Guests:
Guests are only allowed in common areas and must leave by 9 pm on weekdays and 10 pm on weekends. Guests must be sober. Rocky Mountain Sober Living LLC reserves the right to administer UAs/BA tests if necessary.
Fraternization:
There is a zero-tolerance policy for fraternization or sexual activity on the property. Violations will result in immediate discharge.
Cleanliness/Chores:
Members must keep their living space clean and complete assigned chores daily. Random inspections and monthly deep cleans will occur.
Rocky Mountain Sober Living LLC Property:
Members are responsible for any damage to the property. Theft will result in immediate discharge and possible law enforcement involvement.
Smoking:
Smoking is only allowed in the designated outdoor area. Any smoking inside will result in immediate discharge.
Pets:
No pets are allowed, though animals may be allowed in the yard during guest visits. Members must clean up after pets.
Portable Heaters:
Portable heaters are prohibited; electric blankets may be purchased at the member's expense.
Weapons/Firearms:
No firearms or prohibited weapons are allowed on the property, including vehicles. Violations may result in discharge and law enforcement contact.
Program Discharge:
Non-compliance with policies may result in discharge, with members given 30 minutes to collect their belongings.
Consent to Background Check:
Members authorize RMSL to conduct a background check, including criminal and employment history, to verify the information provided for program eligibility.
Grievance Policy:
Rocky Mountain Sober Living is committed to meeting the needs and expectations of our guests. We will work with each guest to try to resolve any conflict and provide a satisfactory outcome for all parties involved whenever possible. Rocky Mountain Sober Living strives to ensure that grievances are handled respectfully, appropriately, and professionally. If at any time a guest of Rocky Mountain Sober Living has a complaint, problem, or concern during their stay, please follow the procedure outlined herein:
1. A Grievance QR code is below for our online form. The form is to be completed; please click enter.
2. If a verbal complaint is being made to the Owner/Manager, they will assist the guests with filling out the grievance online form. The guests will then sign it. A copy will be placed in the guest’s file, and the original will be given to the guests upon request.
3. In either instance, the Owner/Manager will meet with the guests to discuss the complaint/grievance within an acceptable period. They will discuss the nature of the grievance, its impact, and possible resolution
Rocky Mountain Sober Living ensures that all grievances will be followed through with investigation, validation, and recommendation. https://app.onestepsoftware.com/forms/x3Ve3AM
Print name:Text field Text field
DOB:Text field
Signature:Signature
Date: Date
Notice of Confidentiality and Willful Agreement of Terms:
I am voluntarily and willfully entering into a membership to participate in a drug/alcohol-free environment of the Rocky Mountain Sober Living LLC program. I agree to maintain and contribute to the safety, accountability, and well-being of the environment at all times. I agree to remain compliant with all previously stated policies. I understand that if I do not remain compliant, my membership will be canceled, I will be discharged from the program, and I will vacate the premises no later than 30 minutes after being asked.
I agree to continue working on a recovery program and maintain abstinence from all substances for the duration I am a member of the Rocky Mountain Sober Living LLC program. I agree to maintain and protect the confidentiality of all Rocky Mountain Sober Living LLC program members. I will not admit to any unknown persons the names, locations, or any other relevant information regarding other Members, Rocky Mountain Sober Living LLC locations, or any other business conducted. I will NOT use the address for mail or any other relevant purpose.
HB23-1204
Recovery Residence Discharge Policy
Concerning the discharge of a client from a recovery residence.
SESSION: 2023 Regular Session
SUBJECT: Human Services
BILL SUMMARY
The act transfers responsibility for regulating recovery residences from the Department of Public Health and Environment to the Department of Health and Human Services.
Upon admission of a client to a recovery residence, the recovery residence must obtain a signed program agreement from the client regarding the requirements the client must meet to reside at the recovery residence. The residence must also create a relapse plan that must be implemented if the client returns to the use of alcohol or drugs.
The act requires a recovery residence to implement a client discharge and transfer policy to discharge or transfer a client from a recovery residence in certain circumstances. The policy must be approved by the recovery residence's certifying body before a discharge or transfer may occur.
A recovery residence may discharge or transfer a client with 24 hours notice in certain circumstances and immediately discharge or transfer a client if the client is found in possession of alcohol or drugs.
The act requires that prior to discharging a client from a recovery residence, the recovery residence shall provide the client with referrals to treatment or support services, alternative housing options, and recommendations for follow-up care.
A recovery residence shall make its code of conduct, drug screening policy, and discharge and transfer policy accessible in all common areas of the residence and may not discriminate based on age, gender, race, or any other basis prohibited by law when determining whether to discharge or transfer a client.
The act requires the certifying body to establish a grievance and appeal process for clients when they believe they have been wrongfully discharged or transferred from a recovery residence.
The act allows a certified recovery residence or client who is adversely affected or aggrieved by a decision made by the certifying body to appeal the decision to the Colorado Department of Personnel and Administration, Office of Administrative Courts.
APPROVED by Governor May 1, 2023
EFFECTIVE August 7, 2023
NOTE: This act was passed without a safety clause and takes effect 90 days after sine die.
(Note: This summary applies to this bill as enacted.)
I understand that if I relapse, I will be removed from the Rocky Mountain Sober Living Program.
Initials Text field
*NOTE* This membership shall become null and void if I become non-compliant with the above-stated policies. Should I refuse to vacate the property, I will be considered trespassing, and law enforcement will be contacted.
Print Name: Text field
Sign Here: Signature
Date: Date
Communicable Disease Policy
A communicable disease is a disease that can be transmitted from one individual to another via (1) direct physical contact, (2) the air (cough, sneeze or inhaled particle), (3) through a transmission vehicle (either ingested or injected) or (4) through a vector (animals or insects). Examples of some of the most common communicable diseases include measles, influenza, viral hepatitis-A (infectious hepatitis), viral hepatitis-B (serum hepatitis), human immunodeficiency virus (HIV), AIDS, AIDS-related complex (ARC), leprosy, Severe Acute Respiratory Syndrome (SARS) and (COVID-19) and tuberculosis (TB). This definition may be broadened per the recommendations and information from the Centers for Disease Control and Prevention (CDC). Company Name will make decisions involving those with communicable diseases based on medical information concerning the disease in question, the risks of transmission to others, symptoms, and any special circumstances of the individuals involved. The company will weigh potential risks and available alternatives before making any decisions.
Reporting Procedure
Those Members of RMSL who demonstrate signs or symptoms of a communicable disease that poses a credible threat of transmission to one of the houses of RMSL should report that potential infection or disease immediately to the House Manager, who will inform the owner. The Member is then responsible for keeping informed of conditions requiring extended care, missed work, etc. The Member may also be required to provide written documentation from a physician to return to the Facility.
Intake of Members
RMSL will not discriminate against member applicants with a communicable disease. These individuals will not be denied access to the Facility solely because they have a communicable disease but may be excluded from company facilities, programs, and functions if it is determined that restriction is necessary to protect the welfare of the infected individual or others.RMSL will comply with all applicable statutes that protect the privacy of individuals with communicable diseases. Abuse of this policy will result in disciplinary action up to and including termination. RMSL reserves the right to revise this policy without notice during changing pandemic conditions.
Name: Text field
Sign: Signature
Date: Date
GOOD NEIGHBOR POLICY
Good Neighbor Policy
At Rocky Mountain Sober Living, we are committed to being positive members of our community. We aim to demonstrate that we are assets, not "drug houses," and show respect for our neighbors through our actions. By following these guidelines, we help reduce stigma and contribute to a supportive environment for everyone.
Excellence and Humility: Represent yourself with pride and humility, understanding not everyone may appreciate your recovery journey.
Be a Positive Example: You represent the Rocky Mountain Sober Living community and people in recovery. Act with integrity.
Respect the Stigma: Recognize that recovery facilities may still face resistance in some neighborhoods and act to overcome that.
Show Strength and Character: Through your actions, demonstrate that you are working to change for the better and deserve understanding, not judgment.
Limit Group Size: Keep your walking groups small, at most 3-4 people.
Respect Shared Spaces: Be mindful of others in public and in shared spaces; offer help when you can.
Maintain Quiet and Respectful Conversations: Keep voices low, especially in shared areas like the deck or smoking area.
Respect Meetings: Silence phones, stay attentive, and learn from those with long-term sobriety.
Be Polite: Use "Please" and "Thank you," and listen well.
Address Neighbor Concerns Calmly: If a neighbor confronts you, do not engage. Contact Mike Mattice at 719-505-3467 and document the issue if necessary.
PROGRAM PARTICIPANT SIGNATURE:(Required)
Signature
ADD MED AWR ROI Form
(Release of Information)
Rocky Mountain Sober Living LLC
Request for Medical Records- Authorization to Use and Disclose Health Information
RECORDS CAN BE SENT TO info@myrmsl.com, 1716 E Yampa St, Colorado Springs, CO. Please contact us with any questions.
Member's First Name: Text field
Member's Last Name: Text field
Member's Date of Birth: Date
Member's contact phone number: Text field
Members Social Security Number: SSN
Member:
Please fill this out for any offices, therapists, or person(s) with whom we can communicate regarding your care and/or for request of records.
I authorize the following System of Care User Group Agencies, individuals, or programs as listed below to release Medical Records to Rocky Mountain Sober Living and allow for the exchange of information between parties.
I Authorize the Release of Information *
For any Emergency, Contact the Listed Below:
You Must Provide at least One Emergency Contact Name:
Contact
To Any Law Enforcement Officer or officer of the courts.
To Any Medical Office/Health Professional, EMT, or Rescue Personnel.
I understand that information disclosed may be in written, verbal, or electronic form and may include date(s) of contact, locations, and reasons for contact, symptoms presented, treatment progress, outcome information, prescriptions, written referrals, educational records, medical records, tests performed, and/or diagnosis.
I understand that disclosure may include psychological/psychiatric, medical, shelter and case management, and drug or alcohol use information.
I understand that the purpose of this disclosure is to allow the participating entities identified above to access and use the information to establish and maintain continuity of care, better assess the effectiveness of the program, and/or to improve services based on service utilization studies.
I understand that I may refuse to sign this authorization, and no one is conditioning treatment, payment, enrollment, or eligibility for benefits on signing this authorization.
I understand that there is potential for information disclosed, as a result of this authorization, to be re-disclosed by the recipient and, therefore, no longer protected by the HIPAA Privacy Regulations. When applicable, an assessment of the minimum necessary amount of information required has been applied to this authorization.
I understand that I may revoke this authorization, at any time, by giving written notice to the authorized System of Care User Group agencies or programs, except to the extent that action has already been taken to comply with it. Without such revocation, this authorization will expire on, or if left blank, two years from my signature date.
I understand that I am entitled to a copy of this authorization.
By signing the box below, you are verifying you've read, understood, and agreed to all conditions indicated on the Rocky Mountain Sober Living -- ROI (Release of Information) form.
I Consent to ALL of the above. *
Members Name: Text field
Member Signature*
Signature
Date of Consent: *
Date
ADD.MED AWR ROI Form (Release of Information)- Rocky Moutain Sober Living LLC
Form last updated:06/19/2024