Please note that filling out an application does not put you on a waitlist. You must call to follow up or email chelseashousesoberliving@gmail.com
General Information
Todays Date:
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
Contact Information
How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you?
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 REQUIREMENTS:
Rates:
• Single room- $245.00 per week - $980.00 monthly
• Double room-$225.00 per week - $900.00 monthly
Rent is DUE every Friday by 6 pm: $225.00 Per week Double - $245.00 Single Per week
Payments can be made by CASH, VENMO @Chelseas-House, or a check made out to Chelsea's House LLC, 649 Broadway, Malden, MA 02148.
The first and last week of rent are due at the time of entrance.
(Two weeks written notice is required to use the last week's rent) All overpayments on rent are forfeited
Please sign below:
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.
Contacts
Please give us a few people we can contact in an emergency. (Required)
Contact
Insurance
Enter your insurance provider(s).(Requried)
Text field
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
Medications
List ALL the medications you are currently prescribed.
Medication
Employment
Tell us about your employment status.
If you're currently unemployed, select "unemployed" under "type"
EmploymentHistory
If accepted into the program:
One Step Requirement
I, Client first nameClient last name, hereby 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.
Client Signature: Signature Date: Date
By signing below, you are agreeing to the following rules:
NO Alcohol/Drug
NO Weapons, explosives, fireworks
Anyone caught stealing will be discharged immediately.
No non-approved medications( all controlled medications should be kept in a lockbox) All controlled medications are subject to random med counts.
Failed drug screens are subject to discharge. Please see relapse policy
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 the property.
Be considerate of the neighbors and your fellow residents. The volume of the television, music, and your voices must always be considered, especially during the early morning hours and after 9:00 pm.
Each member has daily chores, and 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.
Chelsea’s House reserves the right and the responsibility to search residents' belongings and the residences for illegal substances and inappropriate/hazardous items.
Guests are allowed in the common areas (please see the house guest policy). ABSOLUTELY NO OVERNIGHT GUESTS
Personal items left behind after vacating will be considered abandoned and will be disposed of after 7-10 days
All residents must be in the house from 11 pm-5 am Monday-Thursday, and 12 am-5 am 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 quick cups 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. Provided in handbook located on the first floor in living room
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.