Name: Client first nameClient last name DOB: Client birthdate Social Security #: SSN
Current Address: Client AddressClient CityClient StateClient Zip
Phone Number: Client phone Email: Client email
Facility you're applying to: Text field
Employer: Text field Address: Text field Phone Number: Text field
Emergency Contact and Release of Information:
Current and Past Treatment Center History
Have you ever lived in a half-way, 3/4, or sober house? Radio buttons
Where: Text field When: Text field
Substances used in the past: Text field
Drug(s) of choice:
Client substances of choice
Which 12 step recovery program are you working i.e. AA, NA, CR? Radio buttons
What meetings do you attend: Client kinds of meetings attended
Do you have a sponsor: Radio buttons
If yes, list your sponsor's first name and last initial: Text field
If no, why not: Text field
What is your current source of income: Text field Weekly/monthly income: $Text field
Job Description: Text field How long there: Text field
Do you have a valid driver's license or state ID: Radio buttons
Do you have a social security card for employment: Radio buttons
Do you have a child support obligation: Radio buttons Amount per month: Text field
Do you now, or have you ever been in a relationship with a current kiRC program participant: Radio buttons
Who: Text field
Pending legal matters (please explain):
Have you ever been convicted of a felony: Radio buttons
If yes, please explain:
Are you required to register as a sex offender: Radio buttons
Have you ever been convicted of arson: Radio buttons
Do you have any other mental health diganosis:
Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors: Radio buttons
When: Text field
Current Medications & Dosage:
Are you participating in or about to enter a suboxone or another drug replacement program: Radio buttons
Please list program name and contact information: Text field
How did you hear about us: Client Referred By
Why do you think you are a good fit for sober living:
Applicant's Name: Text field Applicant's Signature: Signature Date: Date
House Leader's Signature: Signature Date: Date
1. I agree not to consume Alcohol and/or Drugs while residing at this property. If I am taking prescription medications (non-narcotic only apart from Medication for Opioid Use Disorder) that are prescribed by a doctor, I will provide that information at the time of initial intake and discuss further use with leadership members.
If I am prescribed prescription medications (non-narcotic only, apart from Medication for Opioid Use Disorder) by a doctor during my stay at this residence, I will contact the house leader immediately to discuss this. I will also discuss any over-the-counter medications with leadership PRIOR to taking them. I further understand that it is my responsibility to avoid ingesting anything (including food), that may cause a false positive reading during drug screens. I understand that if leadership believes that I am under the influence, I am subject to discharge even if a drug screen produces no illicit substance present. Individuals on Medication for Opioid Use Disorder agree to have the levels of the medicine randomly checked to confirm compliance with their treatment regimen.
2. I agree to take random screens for drug and alcohol use administered by leadership upon request.
If the test has a reading for illicit substance use, the program participant will be asked to leave the house immediately. If a program participant is unable to produce a urine sample within 1 hour of the request of the house leader, the urine drug screen/breathalyzer will be considered positive. If for some reason the test is inconclusive, or the leader is uncertain about the results, the program participant will be asked to have a drug screen/breathalyzer performed at an independent laboratory at the discretion of the leader. If that test has a reading for illicit substances (excluding those participating in a Medication for Opioid Use Disorder program producing licit use results), the program participant will be asked to leave the house immediately.
3. I agree not to steal others’ property while I am a program participant of the house. This includes personal property and food belonging to the agency or any other program participants of the house.
4. I agree not to use physical force against anyone in the house while a program participant of the house. This includes threatening and/or verbal harassment of other program participants or leadership members.
5. I agree to pay my program fees on time and in full on the due dates.
6. I agree within the first 30 days to actively seek and obtain full time employment. Employment hours may be substituted with volunteer hours, classes and outpatient treatment if approved by the house leader. The hours of employment must fall in between the curfew for that day. Our program defines full time employment as 32 hours of productivity from activities listed above.
7. I agree to follow the curfew, which is 10 PM Sunday through Thursday and 11 PM Friday and Saturday. In the event I am unable to make curfew, I will contact the house leader to discuss this prior to the curfew.
8. I agree to attend minimum of five Alcoholic Anonymous, Narcotics Anonymous, and/or Celebrate Recovery meetings per week if I have less than one year in recovery and a minimum of four meetings per week if I have over one year in recovery. The house meeting on Wednesday at 6:00 PM and Sunday at 9:00 PM is mandatory. The time of this meeting is subject to change, to be determined by house leadership.
9. I agree to find an AA, NA or CR sponsor and start step work within the first 30 days. I agree to continue doing step work during my entire stay in our program.
10. I understand that overnight stays away from the program are a privilege and must be cleared with the house leader 5 days prior to the date requested. Failure to be in the house after curfew will be viewed as a relapse, and the program participant will be discharged.
11. I agree to show financial responsibility if I bring a motor vehicle on the property, I will provide a valid driver’s license, valid registration, and proof of insurance coverage. Parking privileges will not be provided by facility. I understand that it will be my responsibility to obtain and pay for parking spaces off facility property. To be determined by house leadership.
12. I agree to keep my room clean and orderly, make my bed every morning, as well as maintain the cleanliness of the common areas, daily and as needed.
13. I agree to do the weekly chore that is outlined by the Chore Coordinator when assigned and to participate in any special projects that are requested by the leader of the house. I understand that chores are to be done heavily on Wednesday and Sunday by 6 PM, I agree to check them daily, and clean, as necessary.
14. This residence is smoke-free & vape-free. There is no smoking/vaping inside the house at any time. Smoking/vaping in the house will result in immediate dismissal. Smoking/vaping is allowed outside only in designated areas. Cigarette butts must be disposed of properly.
15. No overnight guests will be allowed, including family members. Any guests will be limited to the common areas of the house and must have at least 60 days clean and sober. No non-program participants are permitted off the 1 st floor of the facility(s) without prior leadership approval. Program participants should bring the presence of questionable guests to the house leader’s attention immediately.
16. I will not engage in an intimate relationship with any other program participant of a ki®RC facility.
17. I agree to commit to a minimum of a 6 month stay if this my first attempt in the program and a year stay for any subsequent attempts.
18. I agree to retrieve my belongings and personal effects no later than 72 hours after leaving the residence. I understand that if I do not, they will be donated to charity.
19. I agree to inform the house leader if I know that another program participant has relapsed. Failure to do so willresult in my dismissal.
20. Quiet hours are from 10pm to 9am. Program participants must be out of bed by 10am.
21. Do not go into any other program participants’ rooms when they are not present. In case of an emergency, two people must be present, and the house leader must be notified.
I have read and fully understand the program guidelines, I understand they are subject to change at any given time, as leadership requires.
Client Signature Signature Date
House Leader SignatureSignature Date
kathy ireland® Recovery Centers (ki®RC) - Laconia SLHProgram Agreement
kathy ireland® Recovery Center and Client first name Client last name(program participant's name) agree to the following program terms:
1. The program fee is $215.00 per week or $840.00 per month
2. The program fee includes room and utilities only.
3. An initial payment of $215.00 for the week or $840.00 for the month is required to move in.
4. Leadership requires one-month notice when program participant is leaving on good terms.
5. Failure to follow any house rules may result in immediate termination from the program, and there will be no refund of program fees paid.
6. The program fee is due on the date of program entry, and subsequent weeks or months depending on which fee the participant chooses to pay.
7. Program participants are responsible for their own food, personal hygiene products, and telephone.
8. Download One Step Client App on cell phone and follow all applicable policies relating to One Step Software.
9. All program fees will be collected through the One Step Software. No cash transactions will occur without prior approval from leadership.
10. Refusal of any One Step policy may result in immediate termination from the program, and there will be no refund of program fees.
11. MENTION LOCATION WITH APP*********************
I understand and agree to the above terms.
Applicant's Name: Text field
Applicant's Signature: Signature
House Leader's Signature: Signature