Intake Form

Resident Requirements

* Resident must not be a register sex offender

* Resident must be at least 30 days sober

* Resident must be working a recovery program

* Resident must be in compliance with probation or parole and in good standing with any legal issues.

* Resident must attend a minimum of 3 weekly recovery meetings (AA/NA meetings, church service, support group, life recovery, therapist, counseling...)

* Resident must be willing to submit to random drug testing

* Resident must agree to work, volunteer, attend treatment or attend school for a total of 30 hours per week

* Resident must sign a 6 month residential agreement

* Resident must agree to maintain sobriety and follow house rules

 

Meraki Recovery Housing page 1

Residential Agreement

Full name: Resident first name Resident middle name Resident last name

Present Address: Resident mailing address

Previous Address: Paragraph

Date of Birth: Resident birthdate

SSN: Text field

ID / Drivers license number and state: Text field

Verified by initials:  Signature

List family member (s):

Contact 1 name  Contact 1 phone

Contact 2 name  Contact 2 phone

Contact 3 name  Contact 3 phone

 

Present Employer: Resident current employment

Address: Text field

Employer/ supervisor contact name and number: Text field

Income per week: Text field

 

Emergency contact Name: Contact 4 name

Relationship: Contact 4 type

Contact phone #: Contact 4 phone

 

Have you ever been convicted of a crime?

Radio buttons

(if yes please explain)

Paragraph

Are you presently in the legal system?

Radio buttons

(if yes please explain)

Paragraph

List any current probation or parole contact names and numbers:

Paragraph

 

Are you addicted to drugs or alcohol? 

Radio buttons

(if yes please explain)

Paragraph

Sobriety clean date: Date

 

Have you ever been to a treatment facility?

Radio buttons

(if yes please explain)

Paragraph

Are you taking any prescription medications? 

Radio buttons

Please list any medications: Medication 1 name Medication 1 notes Medication 3 name Medication 4 name

ALL MEDICATIONS ARE TO BE KEPT SECURED IN A LOCKED SAFE BOX.

 

Have you ever been in a Recovery House, Halfway House or similar facility? 

Radio buttons

(if yes please explain)

Paragraph

Do you currently have a sponsor? 

Radio buttons

If yes please provide contact info: 

Contact 5 name Contact 5 phone

 

Meraki Recovery Housing page 3

Please read and initial to indicate your understanding and agreement:

Signature Program fee is monthly. Payments must be made to Meraki Recovery Housing management. Failure to pay program fee can and will result in eviction. Provided a client departs sober, gives a 30 day notice and is in good standing (packs and carries his/her belongings the day hel she departs, washes and places linen back on his/her bed, cleans his/her respective living area, does not return to premises without permission, etc) he/ she is likely to receive a refund of any over payment, anything less will result in a pro-rated refund or no refund at all. All refunds are given at the discretion of Meraki Recovery Housing management. Departing residents must allow at least 14 days for the processing of any refund.

Signature I realize that the Meraki Recovery Housing sober home for which | am applying for residency requires complete abstinence from drugs and/or alcohol. Any use of drugs or alcohol is strictly prohibited and will result in immediate eviction from our residence. Disruptive and/or discourteous behavior within our residence or community will not be tolerated and can/ will result in eviction from our residence. By initialing/ signing, I acknowledge agreement to the terms stated, and hereby waive my right(s) to normal due process afforded by law.

Signature I have read all the material on this application and answered each question honestly. I have a sincere desire to live clean and/or sober and achieve comfortable recovery from alcoholism and/or drug addiction without relapse. Any questions I may have had were answered to my satisfaction.

Signature: Signature

Date:  Date

Witness: Signature

Meraki Recovery Housing page 4

The following terms and agreement are to be read and fully understood by the undersigned resident of Meraki Recovery Housing LLC.

1. Meraki Recovery Housing LLC is providing the signed resident Resident first name Resident last name a place to reside in their sober living facility located at Text field.

2. I agree to pay a program fee for the above premises on the first day of each month in the amount of Text field. Meraki Recovery Housing LLC retains the right to adjust the program fee within 30 days of notice. If the program fee is not received by the 5th of the month a $25.00 penalty will be charged. If the program fee is not received by the tenth of the month eviction proceedings may be started.

3.1 agree to provide to Meraki Recovery Housing LLC a processing fee of $250 prior to moving in. I fully understand that the processing fee will is refundable only if the following conditions are met. a) Completes 6 months residency b) Gives a 30 written advance notice of moving date c) All possessions are removed and living area is left clean and without

damage If I am evicted for any reason or these conditions are not met I understand that my processing fee will not be refunded. Refunds will be processed within 14 days of move out.

 4. I understands that I will live in the facility under the agreed upon contractual terms and rules as provided and explained, and Meraki management may terminate my residency at any time.

5. Meraki Recovery Housing LLC is providing a sober living facility only and does not provide any counseling, nor restrict the me from making my own personal choices as long as they do not violate the house rules or the resident agreement.

Meraki Recovery Housing page 5

6. Meraki Recovery Housing LLC will provide a housing facility in normal condition, and shall not be held liable by for any injury or loss to myself, or my belongings. I agree and acknowledges that Meraki Recovery Housing is not responsible for any injury or accident and I will forever hold harmless Meraki Recovery Housing LLC unless said provider is negligent in the cause of the loss.

7. I understand that Meraki Recovery Housing LLC, carries only insurance to cover the dwelling and business assets located in the

dwelling.

8. I agree to immediately notify Meraki Recovery Housing LLC in writing of any incident resulting in injury or loss. This will include a full accounting of the incident details.

9. I agree to having a criminal background check completed.

10. This agreement is for the term of six months beginning on Date

 

Signed and dated Checkboxes

Resident: Signature

Date: Date

Resident printed name: Resident first name Resident last name

Meraki Recovery Housing LLC: Signature

Date: Date

Meraki management printed name: Text field

General House Rules/ Requirements/

Guidelines

You are in a sober living program/ environment. Your success and continuance in this program/ environment is dependent upon your consistent good behavior and cooperation. Disruptive and/or discourteous behavior will not be tolerated. Any contact with illegal drugs and/ or

alcohol or any violation of any of the following Rules and Guidelines can/ will result in eviction. Your initials and signature indicate your understanding and agreement.

1. Consumption or possession of beverage alcohol in any form is strictly prohibited.

2. Use or possession of illegal drugs in any form is strictly prohibited.

3. Use and/or possession of drugs and/or alcohol will result in immediate eviction. If evicted for drugs and/ or alcohol the resident agrees to leave the premises immediately and not return for any reason whatsoever, without permission from the House Manager or Meraki management.

4. Dishonesty and stealing are prohibited. If caught you can/ will be evicted.

5. Residents are required to submit to a drug and alcohol screen/ test at any time (24/7) if it is requested. A refusal and/or failure to provide an adequate sample will be treated the same as a positive test result. Any attempt to cheat / circumvent the test will result in an eviction.

6. Weekly attendance of 3 recovery meetings is required (AA/NA meetings, church services, support groups, therapists, life recovery...)

7. Residents are required to complete 30 hours per week of work, treatment, volunteer work or schooling or a combination of any of these as long as it adds up to 30 hours.

8. Smoking is only allowed in the outside back patio area.

9. Meraki Recovery Housing is NOT responsible for a residents personal items/ belongings. Residents are responsible for the security and safekeeping of their belongings. Residents must pack and carry their belongings when they depart from living at the home.

10. If for any reason personal belonging are left behind after moving out of the home or being evicted the resident must then contact the House Manager or Meraki management to arrange retrieval / disposal of their belongings. Meraki Recovery Housing will not store personal belongings for more than 72 hours.

11. Disruptive or discourteous behavior will not be tolerated and can/ will result in eviction.

12. Overnight guests are strictly prohibited.

13. Guests are not permitted beyond curfew hours and are only permitted in the common areas. Guests must not be under the influence of drugs or alcohol.

14. Curfew hours are 11:00 pm Sunday- Thursday and 12:00am Friday and Saturday (If job or meeting hours conflict with curfew they must be pre-approved by the House Manager). Failure to return to the house on time can/ will result in eviction.

15. House meetings are held at a date and time determined by the House Manager and are mandatory for all residents.

16. Overnight/ weekend passes must be requested by filling out a pass request and must be turned in 24 hours in advance. Overnight/ weekend passes must be approved and signed off on by the House Manager and Meraki management. Meraki Recovery Housing management may deny a pass at any time for any reason.

17. Residents are allowed in their bedroom only unless invited and accompanied by the resident who's bedroom it is.

18. Residents are expected to keep their room and the house tidy as well as complete an assigned weekly chore. Residents are expected to make their bed daily, not have clothes on the floor and to clean up after them self's. Kitchen must be cleaned up after each use.

19. Residents are required to wear appropriate dress in the commons area. Sleeping is prohibited in the common areas.

20. Residents with a vehicle must provide proof of a valid drivers license, insurance and have current tabs in order to keep the vehicle on Meraki property. Any inoperable vehicle must be moved off the premise. All Residents must park their vehicles in the driveway (no street parking) and are expected to work together at arranging cars in the order they need to leave.

21. Extension cords are not allowed per city ordinance.

22. No gambling of any type is permitted on the residence.

23. Be accountable, responsible and communicate with your other residents and Meraki management to avoid conflict.

24. Any acts of violence or putting hands on anyone is strictly prohibited on the property and will result in immediate eviction.

25. A violation of any one of the rules or guidelines can/ may result in an eviction.

Resident: Signature

Date: Date

Manager: Signature

Date: Date