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RESIDENT APPLICATION

Humming Bird House , LLC (“HBD”)

At this time, HBD accepts only private forms of payment and provides women-only homes in recovery for 18 years and older. It’s not about the individual, it’s about the environment, which is unique to every other sober living house in Idaho. Our residents are all self-motivated in their recovery.

Upon receiving an application, HBD will contact the applicant via a phone call to pre-qualify them and to set up a time for the applicant and HBD to both express their expectations at the prospective HBD House with either the Live-In House Manager and/or the Director of HBD.  Over-the-phone expectation interviews can be conducted if the applicant's circumstances require it.  You meet us, and we meet you. 

Today's Date  Date

First Name Client first name Last Name Client last name Middle Name Client middle name

(FIRST, LAST, MIDDLE ALL REQUIRED)

State Identification or Driver's License # Text field State of Issue: Text field

Date of Birth: Client birthdate

Phone: Client phone Email: Client email 
(HBD needs at least one of these in order to contact you.)

Where do you currently live? Client Address

 Client City, Client State, Client Zip

In what Cities and States have you lived in during the last 10 years?

Text field      Text field

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Emergency Contact (We will never use your emergency contact information regarding anything other than a true emergency. HBD does not involve itself in your personal life beyond the house.)

Name: Contact 1 name Phone: Contact 1 phone

Email: Contact 1 email Relationship To You: Contact 1 type

Are you CURRENTLY on parole? 

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Are you CURRENTLY in veteran’s court or drug court? 

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Are you CURRENTLY on felony probation? 

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If yes, please list the offense(s) and dates(s): 

Text field

Are you CURRENTLY on supervised misdemeanor probation? 

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If yes, please list the offense(s) and date(s): Text field

If yes to any, Humming Bird House needs the following information and we will be contacting your probation officer in order to express our environment and to inquire about your supervision level (LSI score.)

What is the County and State of your supervision? Text field

Probation Officer Name: Text field Phone: Text field
Email: Text field

Will you sign a release of information with your probation officer for Humming Bird House? 
(*If you wish to be a resident, this would need to be done with your probation officer or his department before we inquire about your status.)

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Are you willing to submit to a background check? 
(*Every Applicant must be background checked prior to signing a Residency Agreement.)

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Have you ever been convicted of a sexual crime or arson? 

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Have you ever been convicted of robbery, burglary, battery, or ANY violent crimes? 
(*ADMISSION OF OFFENSES WILL NOT NECESSARILY DISQUALIFY YOU FROM BECOMING A RESIDENT, BUT MISREPRESENTATION WILL RESULT IN IMMEDIATE DENIAL OF APPLICATION.)

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If yes, please explain and include date(s): Paragraph

Do you suffer from addiction and/or alcoholism? 

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What is your drug(s) of choice?

Client substances of choice

What is your sobriety date? (You are not disqualified if you are not currently sober, but you must enter the house sober.)

Recovery history 1 sobriety date

Are you self-motivated to sustain sobriety through personal growth? 

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Are you currently at an Inpatient Treatment or Outpatient Treatment Program? 

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Where? Treatment center 1 name     City, State: Treatment center 1 city, Treatment center 1 state

Phone: Text field      Counselor’s Name: Text field

If applicable, what is your Patient Identification Number? Text field
(*HBD may need this information to contact you over the phone.)

What is your discharge date? Date

Have you ever lived at HBD or any other Sober Living House? 

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If yes, please include the name and location:

SoberLivingHistory

Are you self-sufficient and can you effectively communicate with others? 
(*Humming Bird House has no clinical staff nor clinical training.)

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Are you suicidal, contemplating suicide, or have you attempted suicide in the past? 

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If yes, please describe: Paragraph

THE IDAHO SUICIDE PREVENTION HOTLINE IS: (800) 273-8255

Have you been diagnosed with mental health disorders beyond alcoholism and/or addiction? 
(*Declaring disorders will not immediately disqualify you from being a Resident.  HBD needs to ensure that we have the support you may need.)

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If yes, please list your mental health diagnosis: Client diagnosis

 

Are you currently taking ANY medications? i.e., medication-assisted treatment for opioid addiction (MAT), insulin, pain medications, Adderall, psychotherapeutic drugs, etc. 

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If yes, please list the medications and reason for prescription:

Medication

AN APPLICANT IS DISQUALIFIED TO LIVE AT A HUMMING BIRD HOUSE IF THEY PLAN ON TAKING, OR CONTINUE TO TAKE THESE MEDICATIONS UPON ENTRY:
BENZODIAZEPINES, STIMULANTS, TRICYCLIC ANTIDEPRESSANTS (TCA'S), OPIOIDS, GABAPENTIN, AND METHADONE (SUBOXONE, VIVITROL, ETC. ARE ACCEPTABLE FORMS OF MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION UNDER A SET OF STRICTLY MONITORED HBD POLICIES).

ALL PSYCHOTHERAPEUTIC DRUGS THAT CANNOT BE USED AS A NARCOTIC ARE ACCEPTABLE, BUT HBD MANAGEMENT DOES NOT HOLD, DISTRIBUTE, ADVISE, OR CONSULT FOR THE USE OF ANY HBD-PERMITTED PRESCRIPTIONS.

 

HBD is a zero-tolerance sober living house.  If relapse occurs, the Residency Agreement will be terminated and the individual must leave the HUMMING BIRD House under the direction of HBD Management, which could be to leave immediately. In this case, HBD will take steps to try and help ensure the individual has a place to go. The individual is welcomed and encouraged to reapply after a 30-day period. This is NOT an imposed penalty. In the Founder's experience of living in over (10) sober living houses and now operating them, it is the only way to keep a house a legitimately sober and safe environment, and not a house where people don't use or drink that much but continue to live there. It is what is best for our HBD Houses and the rest of the individuals living there.

In case of relapse and your Residency Agreement is terminated, do you have any plans in place?

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If yes, what are they? Paragraph

In case of relapse, should HBD notify anyone?

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If yes, who?

Name: Contact 2 name Phone: Contact 2 phone

Email: Contact 2 email Relationship To You: Contact 2 type

Do you have a vehicle that will be parked at or near the HUMMING BIRD House? 

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Will you be self-paying the residency fee, or be receiving financial support through family, friends, and/or community support?

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Are you currently receiving SSI/SSDI?

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Are you currently employed? 

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If yes, what do you do for work?

Employment 1 type   Employment 1 notes  Employment 1 type

If no, do you intend to search for work in the near future, or once your treatment schedule allows you to have the time to?

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How did you hear about Humming Bird House?

Client Referred By

Do you have any questions or concerns that need to be addressed in a conversation upon HBD contacting you to pre-qualify your future residency?

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What is the date that you would like to move into Humming Bird House? Date

 

New Applicant Signature: Signature