B House Intake Form

APPLICATION PROCESS

1. COMPLETE APPLICATION AND SUBMIT FORM

2. COMPLETE INTERVIEW WITH HOUSE MANAGER

3. IF ACCEPTED, ARRANGE TIME AND DATE OF ARRIVAL

(Acceptance letter will be issued AFTER completion of the above process)

 

 

 

NAME: Resident first name Resident last name  DATE OF BIRTH:Resident birthdate

DRIVERS LICENSE: Text field STATE: Text field

PHONE#:Resident phone EMAIL: Resident email

EMERGENCY CONTACT: Contact 1 name RELATIONSHIP:Contact 1 type

ADDRESS: Text field

CONTACT PHONE#:Contact 1 phone

MEDICAL INFORMATION
How long have you been sober? Resident sobriety date

Drug(s) of Choice:Resident substance of choice

Which meetings do you attend? (AA, NA, CA, SMART Recovery, Refuge, Faith, etc.) Text field

Sponsor Name and Phone# (If Applicable): Contact 2 name Contact 2 phone

List any medical conditions:Resident diagnosis

 

List any prescription medications: 

Medication #1

Medication: Medication 1 name Dosage: Medication 1 dosage

Quantity: Medication 1 quantity Category: Medication 1 category

Frequency: Medication 1 frequency MD: Medication 1 md

Notes: Medication 1 notes

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Quantity: Medication 2 quantity Category: Medication 2 category

Frequency: Medication 2 frequency MD: Medication 2 md

Notes: Medication 2 notes

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Quantity: Medication 3 quantity Category: Medication 3 category

Frequency: Medication 3 frequency MD: Medication 3 md

Notes: Medication 3 notes

 

 

 

RESIDENT INFORMATION 

Have you ever lived in a Sober Living home? 

Radio buttons

If yes, which one? Text field

Are you involved in any legal action?

Radio buttons

If yes, please explain:Paragraph

Are you required to register as a sex offender?

Radio buttons

 

Have you ever been convicted of arson?   

Radio buttons

 

A felony?  

Radio buttons

How many? Text field

Source of Income: Resident occupation Salary (Weekly/Monthly): Text field

 


IMPORTANT NOTICE: B-House is a recovery home which requires expulsion, without prior notice or refund of deposit and fees, of any resident member who is found to be: 1) using alcohol or drugs; 2) engaging in disruptive behavior; or 3) in default of payment of weekly membership fee. All resident tenants of B-House are members of our recovery home. You do NOT have renter’s rights or any rights of tenants pursuant to the New Jersey Property Code, and expressly waive any such rights in exchange for membership privileges.

I have read the above notice and understand that I am applying or membership of B-House as a member of a recovery home. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules of the home, which include periodic/random drug testing. I understand that I am subject to immediate expulsion from the home if any of the following occur: 1) I use alcohol or drugs (other than prescribed medication); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior); 3) I fail to pay my weekly membership fee. I understand that if I leave voluntarily an at least 30 days’ notice is given or I am expelled from B-House. I understand that my deposit and member fees will be forfeited.

By signing below, I certify that the information contained in this application is true. I have read and understand the B-House house rules and policies. I understand and accept the above conditions set forth form membership to B-House and agree to abide by said conditions should I be selected as a member resident.

 

SIGNATURE OF APPLICANT: Signature

DATE: Date

 

TO BE COMPLETED AT TIME OF INTERVIEW

 

The membership application was reviewed with the applicant and he/she acknowledged the IMPORTANT NOTICE and requirements for membership in B-House set forth above. The applicant has reviewed the B-House house rules.

 

SIGNATURE OF HOUSE MANAGER: Signature

DATE:Date

(TO BE COMPLETED UPON ARRIVAL AS A MEMBER RESIDENT)

I have received a copy of the house rules and policies. I understand that failure to follow the rules and/or responsibilities in monetary fines and/or expulsion from B-House. In the event of expulsion, I understand that any fees/deposits paid to the house will be forfeited.

 

NAME OF RESIDENT MEMBER: Text field
(Please Print)

 

SIGNATURE: Signature

DATE: Date