Application for Residents

 

 

 ****If you are in treatment please have your case manager email us @ chelseashousesoberliving@gmail.com for a follow up.****

Please contact Mari Santos via phone or text 857-326-2315 (cell) 781-666-3752 (office) - after all submissions to learn about bed availability.  


Click next to begin!!!

General

Tell us about yourself

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

Contact Information

How can we reach you?

What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
 
We have homes in Chelsea, East Boston, Lynn and Malden ( East Boston and Lynn are the only options for females) 
 
Please select a preference: 
 
 Dropdown
 
 
Rent is DUE every Friday by 6pm: $200.00 Double - $225.00 Single
 
Payments can be made by CASH, VENMO Chelseas-House, Check can be made out to Chelsea's House LLC 649 Broadway Malden, MA 02148. 
 

Contacts

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

Contact

Insurance

Enter your insurance provider(s).

Insurance

Medical History

Tell us about your medical history.

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

Medications

List the medications you are currently prescribed.

Medication

Treatment Centers

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

TreatmentCenterHistory

 

 

Employment

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

EmploymentHistory

 

By Signing below you are agreeing to the following rules: 

 

NO Alcohol/Drug

NO Weapons, explosives, fireworks

Anyone caught stealing will be discharged immediately.

Failed drug screens are subject to discharge. (quick cup or labs) 

Smoking inside the house is not permitted. Ashtrays are provided outside and need to be cleaned daily. No littering of cigarette butts on or near property.

Be considerate with the neighbors and your fellow residents. The volume of the television, music and your voices need to be always considered, but especially during the early morning hours and after 9:00 pm.

Daily chores for each member, also individuals need to clean up after themselves. Wash your dishes immediately to prevent roaches and other insect problems. Place garbage bags in the garbage containers outside.

Food is not permitted in the bedrooms.

Guests are allowed until 11:00 pm and midnight on weekends in the common areas only. ABSOLUTELY NO OVERNIGHT GUESTS

Personal items left behind after vacating will be considered abandoned and will be disposed of.

All residents must be in the house during the hours of 11pm-5am Monday- Thursday, 12am-5am on Friday and Saturday. After 30 days of residency, you may apply for an approved overnight pass.

Drug tests will be performed twice weekly by an outside lab and randomly at staff discretion.

There will be one (1) mandatory house meeting per week.

Required to attend three (3) outside meetings weekly.

Read and understand all of Chelsea’s House policies and procedures.    

 Signature

 

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.