Fee Schedule Agreement
I, Client first name Client last name understand and acknowledge that I am entering into a faith based recovery program. My enrollment in this program is voluntary.
Please check the option that applies below:
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DUE ON FIRST DAY OF STARTING PROGRAM:
Initial starting program fee = $375.00 (includes 2 Weeks)
WEEKLY FEE = $160.00 Fee due dates: 1st, 8th, 15th, and 22nd of each month. (Program fees paid on the 22nd cover the remaining days of the month for however many days that are left.)
If you balance is not at zero, restrictions will apply. (NO OVERNIGHT PASSES, DAILY CURFEW, AND OTHER PRIVELAGES AT DISCRECTION OF STAFF; INCLUDING GETTING RELEASED FROM THE PROGRAM)
If you are past due; 75% of all compensation to you (from any source), goes towards paying said fees.
House fees are a priority, you should be able to budget and plan for other expenses, such as food, fines, court costs etc. Most courts and P.O’s will work with you as they understand that housing is a basic primary need. If you are having any issues please get with your house manager and/or program coordinator to resolve any conflicts prior to spending any income.
Strict adherence to this is MANDATORY; we consider any violation as theft and will terminate you from the program immediately.
Signature: Signature
Manager: Oren Golanski Date: Date
Contract
Anchor of Hope Sober Living Resident Contract
Anchor of Hope Sober Homes (AOHSH) requires 100% abstinence from drugs and alcohol. I understand that by choosing to live in this home, I am agreeing to ALL rules and requirements of the program. I understand that I will need to adhere to any further requests and failure to do so will result in my choosing to leave AOHSH. I agree to report any activity from other residents for the well being of my community. I understand that if I choose to use and/or drink, I am choosing to leave AOHSH and the program. I understand that I will not argue or justify my use. I understand that if I choose to violate this policy, I will leave the program peacefully. I understand that any reefusal or failed drug test is me choosing to immediately leave AOHSH. I further understand that any BAC over 0.00 is grounds for dismissal and my choosing to leave AOHSH.
I understand that I am not a tenant and I do not pay rent. I am a program participant and I pay program fees. I understand I am not entering into a lease agreement. I understand that Anchor of Hope Sober Homes provides housing as part of my participation in the program as long as I choose to follow the rules outlined in this contract. I understand that if I chose not to follow the rules of this contract that I may be discharged from the program which includes the housing provided to me
1. I understand that I am required to attend a minimum of 4 meetings a week. This inlcudes IOP, AA, NA, CA, Church, Bible Study, Celebrate Recovery, etc. I understand this does not include meeting with my sponsor or individual therapy. I understand that failure to make 4 meetings within a week will result in a $20 fine and mandatory 5 meetings the following week. I further understand that if I do not make my mandatory 5 meetings I am choosing to leave AOHSH.
I understand that in order for a meeting to be counted I must chec in on the group chat. I understand that this should be done on my arrival at the meeting. Weekly meeting counts go from Sunday 6 PM to Sunday 5:59 PM. I understand that attending meetings is an important part of my recovery. I understand that it is highly suggested I find a "home group" and get involved in the recovery community. Connection is the opposite of addicition.
2. I understand that I am required to have a sponsor within the first 30 days of entering the program/ I understand that I should continually meet with my sponsor and work a program. I understand that to not have a sponsor and work a program within 30 days is my choosing to leave AOHSH.
3. I understand that there is Zero Tolerance for stealing. I understand that tape and sharpie will be provided for me to label my food. I understand that I am repsonsible for not taking something that is not labeled as mine. I understand that stealing and/or using food taht is not mine, is my deciding to leave the program.
4. I understand that there is zero tolerance for destruction of Anchor of Hope Sober Homes property. I understand this includes: Walls, doors, windows, and furniture. I understand that if I didn't bring it, I shouldn't break it. I further understand that if I destroy AOHSH property, I will be held financially responsible and will be my deciding to leave AOHSH.
5. I understand that there is zero tolerance for physical and verbal assault. I understand that if I touch another resident in a threatening manner or I threaten anyone verbally, I am making the decision to leave AOHSH. I understand that depending on the severity of my actions, legal action may be taken as well.
6. I agree to keep personal belongings and personal space neat, clean, and orderly at all times.
I understand and agree to making my bed every morning - no exceptions. I also understand it is my responibility to wash and fold my personal linens weekly. I understand the importance of and agree to showering every day (no exceptions).
I understand that part of recovery is creating new haits. I agree to complete the household chore(s) that are assigned to me in a complete and timely manner.
I understand that after using kitchen items that they need to be washed, dried, and put back (plates, silverware, pots, pans, etc).
I understand that my personal space should reflect the life that I am living - CLEAN.
I understand that if I have chronic issues with cleanliness and not doing chores, I will be given the chance to improve. I understand that if this is a continued issue with me, I will be making my own decision to exit AOHSH.
Fine: $10/unmade bed, $20/missed chore
7. I understand that I am not to touch the thermostat at any time.
Thermostats should be set at 70 degrees during summer and 68 degrees during the colder months.
Fine: $30
8. I understand and agree to only use tobacco products in designatred areas outside of the home (in most cases, this is in the back). I agree to dispose of my butts, filters, etc in the proper, provided receptacles.
I understand that smoking and/or vaping in any AOHSH house is making a decision to leave AOHSH.
9. I understand that suboxone treatment is a privilege and there is a certain protocol to be followed if I am prescribed suboxone. I understand that suboxone will be held by my house manage and distributed in weekly increments at the house meeting. I understand that my weekly allotment should be kept out of sight from other housemates. I understand that AOH holds the right to conduct counts at any time. I understand that if my count is off this is my choosing to leave AOHSH for abuse of a narcotic.
AOHSH highly encourages a MAXIMUM of 8 mg a day. However, we will work with individuals to get this dosage as needed.
10. I understand that my personal medications should be kept out of sign from other residents. I understant that this can be triggering to others and disrespectful. I commit to keeping my medications and dosages to myself and not discussing it with others.
11. I understand and agree to be out of my bed by 10:30 AM and remain so until 4 PM unless authorized by an AOHSH staff member. I understand if I have outside employment, I am exempt from this rule.
I understand that if I am unemployed and/or owe a balance I will need to leave the house by 8:00 AM in search of employment. I agree to turn in a minimum of 5 applications a day before returning home. I understand that if I am conducting a job search from home, I need to submit 20 applications a day.
I understand that if I am disabled and unemployed that I need to be up by 8:00 AM and remain so until 3:00 PM to remain active in my recovery. I also understand and agree to possible service work that may be assigned at the discretion of the AOHSH director.
I understand and agree to documenting all efforts made in obtaining employment. Including, but not limited to, dates, times, phone numbers, and manager names. I further understand that my job search is subject to verification by AOHSH staff.
12. To build accountability and a positive structure, I understand the value of curfews. I understand that residents of the AOHSH's Program must be in by 11:00 PM daily Sunday through Thursday.
I understand that residents of AOHSH's program must be in my Midnight on Friday and Saturday.
I understand that curfew means inside the building, not just on the premises.
I understand that if I am late arriving I may be subject to an immeidate UA at my own expense of $20.
I understand that if I have a meeting or employment outside of this curfew, I must get it approved by the AOHSH director.
I understand that there is a "lights out" policy of 11:30 PM Sunday to Thursday. This is extended to 1:00 AM on Friday and Saturday. After "lights out" I agree to be quiet and respectful of others in the house.
I understand that personal electronics must be used with personal headphoens so as to not disturb fellow participants.
I understand that curfew is lifted at 5:30 AM every morning.
13. I understand that sexual displays of affection will not be tolerated in the home. I understand that my actions can be seen on camera.
Fine: $50
14. I understand that in order for someone to visit me AOHSH they must be sober. I understand that I need to inform my house manager/director of any visitor(s) using the group chat.
I understand that house guests are NOT allowed in ANY bedrooms. NO women in the men's bedroom. NO men in the women's bedrooms. I further understand that ANYONE of romantic involvement or interest are not allowed in bedrooms.
Guests are allowed to use the restroom.
I understand that guests/visitors should be off the property ONE HOUR prior to curew. 10 PM Sunday to Thursday and 11 PM Friday to Saturday.
I commit to being mindful and respectful of my guests length of stay. I understand this is a shared home and will keep visits to a maximum of 2 hours.
I understand that continual disregard for this rule will result in my leaving AOHSH.
Fine: $20
15. This recovery housing opportunity provides random drug screening as a service to all residents. I agree to participate in this service as a part of my recovery. I understand that these tests can happen without notice and with or without cause or explanation.
I understand that failure to test will be considered a positive test and that I am making a decision to leave if I do not test. I understand that if I fail to test within one hour of a request, this too, will be considered an automatic positive result.
I understand that if I am found to be intoxicated or fail a drug test, I may be given the opportunity to go to detox or a 72 hour dismissal. I understand that a “72” is not automatic and/or a given. I understand a “72” is considered when a resident is honest about their drug/alcohol use and takes responsibility for their actions. I understand that the opportunity for detox and/or a “72” is solely at the discretion of management.
I understand that if I am immediately discharged from the program, I will be supervised and given 45 minutes to remove ALL items I can carry immediately. Upon immediate discharge, AOHSH will hold all items for up to 3 days. I understand that ANY items not claimed after 3 days will become the property of AOHSH.
I understand that in the event I am allowed a “72” - I must return at the agreed upon day and time and PASS a drug screen for re-entry. I understand that fees and fines must be current in order to be eligible for a 72 hour dismissal and to re-enter the home.
16. Overnight Passes are an opportunity and privilege granted as I grow in my recovery. I understand that when I achieve 31 days, working a successful program, have my area clean, assigned chore(s) completed, have attended my required meetings, and have my dues current, I will be granted 2 overnight passes per week.
I understand that overnight requests must be submitted at least 24 hours in advance.In order to request an overnight, I commit to starting a group text with myself, my house manager, and my director requesting the day(s). I understand that same day requests will not be approved.
I understand that a 72 hour leave due to drug or alcohol use restarts the 30 day waiting period for overnights.
17. I understand the importance of turning off lights and locking the front door. I commit to turning off lights when leaving a room and locking the front door when I leave.
FINE: $5 for lights
18. I understand, consent to, and acknowledge that cameras are present in the common area of the home. I understand that any tampering with the cameras in any way is me choosing to leave AOHSH.
19. In an effort to support a family-like atmosphere, each house in the AOHSH program has a weekly House Meeting. This meeting will allow all residents to review current guidelines and make suggestions for change. House Meetings are also an opportunity for individuals to learn about areas to grow in responsibility at AOHSH.
I understand that these meetings are not optional and that I will exhaust every option with my employer and schedule to attend. I understand that if I am on an overnight, I must return in time for the house meeting unless previously arranged and approved by management.
I agree to attend this weekly House Meeting to strengthen my sense of community and connection at AOHSH. I acknowledge and understand that AOHSH may have other mandatory functions outside of House Meetings. I understand that I will be given plenty of notice of these functions so that I may arrange my schedule to attend.
If I choose not to attend House Meetings and/or mandatory functions, I understand that I am making a decision to leave AOHSH.
FINE: $10/being late to meeting $20/missed meeting
20. I understand that the AOHSH Weekly Feedback is due at the beginning of our house meeting. I commit to using the notebook provided to write out my answers each week.I understand that this exercise is to strengthen my recovery and is to benefit my personal growth.
FINE: $5/not completing weekly feedback form
21. I understand that the program fees are as follows:
Entry Fee: $375 - this covers 2 weeks of program fees and is non-refundable.
Program fees: $160/weekly or $640/monthly
Fee due dates: 1st, 8th, 15th, and 22nd of each month. (Program fees paid on the 22nd cover the remaining days of the month for however many days that are left.)
In the event that a resident is discharged due to a failed drug screen or admission of use, any program fees paid for that week are forfeited. Any program fees paid in addition to the current week will be refunded.
Weeks Run: 1st - 7th, 8th - 15th, 16th - 22nd, 23rd - end of month. These are listed specifically for clarity and transparency.
Preferred method of payment:
22. I understand that AOHSH requires a 1-week notification if I plan to leave the program. I understand that not providing a 1-week notification is me relinquishing any and all monies paid to the program. If I do provide an approved 1-week notification, any program fees paid ahead of the current week will be refunded within 10 business days. I understand that AOHSH does not provide any prorated refunds for the current week.
23. I understand that if I owe more that $320 in fees, I will not be approved for overnights, I will not be allowed to go to 10pm meetings and I must get with the Executive Director to create a payment plan.I understand that once I am on a payment plan, inability to follow the payment plan is my choosing to leave AOHSH. I further understand that if my balance reaches $480 I am choosing to leave AOHSH.
24. I understand that Recovery is a spiritual program. I understand that it is highly recommended that I get involved with a religious program of my choosing.
25. I understand that each house has its own parking policy, per neighborhood ordinance. If I have a vehicle, I agree to abide by the policy my house sets forth. I also agree to basic driveways, to not park on grassy areas, to not park in emergency/fire zones, to not park in areas marked “No Parking”. I understand that by not following the rules of parking, I am choosing to leave the program.
Communication and honesty are essential parts of both recovery and everyday life.One of the best components of AOHSH is our ability to individualize care. We are more than willing to work with people in most situations.However, we need to be made aware of these situations - it is your responsibility to inform us. We are available 24/7. Feel free to reach out to any staff at any time.
Thank you for being the best part of Anchor.
Josh Bone 704.912.8072
Oren Golanski 704.706.3236 J
ennifer Arena 919.360.1611
Nicole Young 720.625.2747
Jonathan McCullen 980.310.4715
David Lancaster 704.241.4977
I Client first nameClient last name have read and understand the requirements and expectations of Anchor of Hope Sober Homes. I agree to uphold the values and principles of living a sober life and representing this program. I agree to comply and adhere to the rules and guidelines of being a resident at Anchor of Hope Sober Homes.
Signature Resident signature
Signature Staff Signature
Move-in date Date Resident Initial Initials Text field
Head Director (print): Oren Golanski
Director Signature:
Date: Date
Background Check Authorization Form
To whom it may concern:
I Client first name Client last name give consent and permission to Anchor of Hope to compile and request a complete criminal background/history. This criminal background check shall remain in my file.
Client Signature:
Signed: Signature
Date: Date
Liability Waiver Advertising/Photo Release Form
AOH will occasionally take photos of residents during activities and/or classes or at other times for the purpose of use in our website, brochure, or other advertising materials. We respect your privacy and would never use your image in our advertisements unless you specifically allow us to do so.
In consideration of my engagement as a model, upon the terms here with stated, I hereby give to Anchor of Hope legal representatives and assignees, those for whom AOH, and those acting with AOH authority and permission:
a) The unrestricted right to copyright and use, re-use, publish, and re-publish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction my own or factious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.
b) I also permit use of any printed material in connection therewith.
c) I hereby relinquish any right I have to examine or approve the completed product or products or the advertising copy or printed matter that may be used in conjunction therewith or the use to which it may be applied.
d) I hereby release, discharge and agree to hold harmless Anchor of Hope, their legal representatives or assignees, and all persons functioning under AOH permission or authority, or those for AOH is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.
e) I hereby affirm that I am over the age of 18 and have the right to contract in my own name. I have read the above authorization, release and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assignees.
Name: Client first name Client last name
Signature:
Signature
Date:Date
WAIVER OF LIABILITY
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
1. In consideration for receiving permission to participate in the Anchor of Hope, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Anchor of Hope, their officers, agents, or employees(hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in such activity, while in, on or upon the premises where the activities are being conducted, REGARDLESS OF WHETHER SUCH LOSS IS CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise and regardless of whether such liability arises in tort, contract, strict liability, or otherwise, to the fullestextent allowed by law
2. I am fully aware of the risks and hazards connected with the activities of Anchor of Hope, and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of being in the Anchor of HOpe Sober living program, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise, to the fullest extent allowed by law
3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage, or costs, including court costs and attorneys fees that Releases may incur due to my participation in Anchor of Hope, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise, to the fullest extent allowed by law.
4. It is my express intent that this Waiver and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of North Carolina and that any mediation, suit, or other proceeding must be filed or entered into only in North Carolina and the federal or state courts of North Carolina. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions.
IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Wavier of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age or guardian of minor child and fully competent; and I execute this Agreement for full, adequate and complete consideration fully intending to be bound by same.
PARTICIPANT: Client first name Client last name
Participant signature:
Signature
Date: Date
Head Director: Text field
Date:Date
Proof of Residency
DATE:Date
To whom it may concern;
This letter is to certify, Text field has been a resident with Anchor of Hope Sober Living since Date He/She currently resides at: Text field
This letter is to certify that, Text field pays $640 monthly in program fees, including utilities for his/her home at Anchor of Hope Sober Homes. Food is not provided. Please contact me directly with any questions or concerns regarding these fees.
Paragraph
Sincerely,
Text field
Anchor of Hope Medication Policy
Anchor of Hope Sober Homes does not allow any narcotic medications except Suboxone. Participants are allowed to maintain possessin of a 7 supply of suboxone. Any remaining medication will be counted and locked up in the house safe. Participants will be given access to their medication for their weekly supply and once again counted to maintain a proper pill count.
o Anchor of Hope does not administer medications.
o Clients will sign for their medication when they accept possession for self-dispensing.
o All other non-narcotic prescriptions are allowed only if they are prescribed to you by a doctor and are taken as prescribed.
o Medications are not shared with any other resident. Residents are responsible for taking care of their own prescription medications.
o You may not consume anything nor bring on property anything that contains alcohol, including but not limited, to over the counter medications or mouth wash.
o All medications must be disclosed, and at any time staff deems necessary, medications may be counted to confirm accuracy of dosages taken.
o Any changes in dosage must be confirmed in writing or by telephone to staff from the issuing doctor. This includes discontinuing of prescribed medications.
o Do not leave medications out where they are in the open or unprotected. Keep in a dresser drawer or with you at all time.
o You are responsible for the control or your non-narcotic medications and any deviations are considered abuse.
o Abuse of any medications will be considered a relapse and may lead to termination from the program.
o Any medication not used, will be turned in to the house manager to be locked up and turned over to the Director for disposal.
Client: Client first name Client last name
Date:Date
Client Signature:
Signature
Director: