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
Do you have any regular medical appointments?
Text field
Are you on Probation or Parole?
Probation
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Do you have any special medical equipment?
Client notes
Have you been exposed to someone with COVID-19? IF YES, please explain when what are your symptoms:
Text field
Are you currently experiencing any of these symptoms: Fever, Dry Cough, and/or Flu-like Symptoms
Text field
Have you had any of the following tests?
Medical Tests
Resident Suitability Questionnaire
Tell us more about your activity of daily living.
Can you walk independently Checkboxes
Can you participate in household cleaning and chores? Checkboxes
Can you bath and dress yourself? Checkboxes
Do you bath every day? Checkboxes
Do you have any issues with bladder control Checkboxes
Do you smoke tabacoo cigarettes? Checkboxes
List your favorite foods:
Text field
List Activities you enjoy doing:
Text field
List concerns you may have living with a roommate?
Text field
Do you work or volunteer anywhere?
Text field
List ANYTHING else we should be concerned about.
Text field
Occupancy
What date will the you be moving in?
Client admit date
FEES
Initials Text field Initial placement at Claude’s House may be supported by scholarship, grant, or third-party funding. Upon completion or expiration of that funding, residents are required to pay the standard weekly fee of $225.
Initials Text field The licensee, licensee’s representative and/or licensee’s legal representative agree that the Resident (or other specified party) will pay the basic rate as of the date of this agreement, which is $225 per week and a non-refundable move-in fee equal of $200.
Initials Text field Payment is due the 1st - 4th of each month depending on the date that the licensee receives their income.
Financial Information
Expenses: Cell Phone Car Loans Other
Text field
What is the total of your monthly expenses? $ Text field
Living Arrangement
Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
House Standards
Break these rules and your stay will be terminated
You have 1 warning
Kitchen Standards:
SAFETY:
Keep the kitchen floor dry. Wipe up any spills immediately and place a wet floor sign if needed.
The kitchen closes at 9 PM.
GENERAL:
Do not use another resident’s food or kitchen items without permission.
Food is only to be consumed in the kitchen. No food allowed in bedrooms.
Never leave personal items unattended in the kitchen or dining area.
Respect shared space. Keep noise and conversation at a reasonable level.
Turn lights and fans off when leaving.
CLEANLINESS
Place all kitchen trash bags in the outdoor trash bin nightly. Do not leave waste on counters, tables, or inside the home.
Wash your dishes immediately after use. Dirty dishes may not be left in the sink or anywhere in the home at any time.
Clean up all messes, crumbs, spills, and food splatter after each use.
Wipe down counters, stove, microwave, and table after cooking.
Label and store your food properly.
PERSONAL HYGIENE:
Wash your hands before preparing food.
Dispose of diapers, hygiene items, or personal waste in proper trash bins outside — not the kitchen trash.
Keep yourself clean and avoid bringing any offensive odors into the kitchen area.
Bedroom:
SAFETY:
Bedroom doors may be closed but must remain unlocked at all times.
Keep floors clear — no items that could cause slips or falls and place a wet floor sign when needed.
Do not open the screen window or throw anything out the windows.
GENERAL:
You may NOT enter another resident’s room at any time.
Keep your bedroom door closed at all times but must remain unlocked at all times.
All personal items must stay within your assigned personal space/storage and valuables should be secured.
Do not eat in the bedrooms and dispose of any food items only in the kitchen or outdoor trash; this helps prevent rodents and insects.
Turn lights and fans off when leaving.
CLEANLINESS
Your room must be kept in an orderly and sanitary condition at ALL times.
Make your bed daily and keep clothing/items stored properly.
Do not eat in the bedrooms and dispose of any food items only in the kitchen or outdoor trash; this helps prevent rodents and insects.
Immediately clean up any spills or messes in your room and place a wet floor sign when needed.
MATTRESS & FURNITURE:
Mattress covers must NEVER be removed.
Do not damage or alter any bedroom furniture or fixtures.
Report any broken items or maintenance needs to staff.
INSPECTIONS:
All rooms are subject to monthly/random inspection by Claude’s House staff for cleanliness, safety, and policy compliance.
Bathroom:
SAFETY:
Bathroom doors may ONLY be locked while you are using them.
If you spill anything on the floor, immediately wipe it up and place a wet floor sign when needed.
GENERAL:
Do not leave any personal items in the bathroom.
Respect others’ privacy. Do not enter while someone else is in the bathroom.
Turn lights and fans off when leaving.
CLEANLINESS
Put trash in the trash can.
Clean up after yourself after using the bathroom.
PERSONAL HYGIENE:
Dispose of diapers, bed pads, or any personal hygiene items properly.
Avoid leaving offensive smells. Spray the bathroom after use.
Living Room:
SAFETY:
Keep walkways clear—do not leave bags, shoes, or belongings on the living room.
If any spills occur, clean them immediately and place a wet floor sign if needed.
GENERAL:
Respect others using the living room — keep conversations and noise at a reasonable level.
The living room is for relaxation and socializing — no aggressive behavior, arguments, or loud disruptions.
TV Hours:
Sunday – Thursday: 6 AM – 11 PM (TV off at 11 PM)
Friday – Saturday: 6 AM – 12 AM (TV off at 12 AM)
CLEANLINESS
Keep furniture, floors, and surfaces clean.
Wipe up spills and place a wet floor sign when needed.
Pick up trash and personal items after using the space.
Respect shared furniture; avoid damaging couches, chairs, or tables.
Laundry
SAFETY:
Keep area clear around washers and dryers.
Wipe up any spills or water on the floor immediately and place a wet floor sign when needed.
Do not overload washers or dryers.
GENERAL:
Use laundry only on your assigned day or make-up days.
Only use quarters in coin-operated laundry.
Do not borrow money from other residents to do laundry. The office has change available if needed.
Do not wash another resident’s clothes.
Do not put feces or heavily soiled items into the washer or dryer.
CLEANLINESS
Keep the laundry area clean — wipe up spills and remove lint from dryers and place a wet floor sign when needed.
Remove your laundry promptly when the cycle is finished.
Place trash in the trash bin if needed.
PERSONAL HYGIENE:
Dispose of diapers, bed pads, or hygiene items properly — never in the laundry machines.
Computer/Internet
Fill in your name, time in, and time out before using the computer.
Each resident may use the computer for 1 hour at a time.
Allow another resident a turn before signing up for an additional hour.
If you finish early, leave a 15-minute buffer before the next person begins.
Do not use this computer for any inappropriate activity. Violation may result in termination of your residence.
Do not save personal information on the computer. All data is cleared periodically.
Do not leave personal information unattended. Claude’s House LLC is not responsible for lost or stolen personal information.
BEHAVIOR:
No aggressive or violent behavior EVER!
No profanity or offensive language directed at any residents, neighbors, or Anchor staff or helpers
No lending, making change or borrowing money, cars or other property from other residents or neighbor
All residents must attend outpatient treatment
No romantic advances on Claude’s House staff
SMOKING, ALCOHOL, AND DRUGS:
Smoking (including vaping) on backyard ONLY
No Alcohol consumption or storage of alcohol in or around premises
Do not share medication
No storage or use of illegal drugs or unprescribed medication allowed
Everyone must complete a negative UA during intake process and is subject to random UA twice a month
ADDITIONAL EXPECTATIONS:
No loitering or hanging out in the front yard for any reason. The backyard is used for this.
Keep entry and exit doors closed and locked at all times
No weapons, drugs, or paraphernalia of any kind
Do not steal or use another person’s items without permission.
Do not open or enter any cabinets or closets with locks
Clothes must be worn outside of your room.
Never leave personal items unattended in common areas of the home
In case of an emergency, we need all residents to sign in and out of the home when leaving the property.
Residents can enter/exit the home during these hours ONLY:
6AM-11PM Sunday – Thursday
6AM – 12AM Friday and Saturday
48 hour prior written notice must be given for any & all exception
Residents must adhere to more strict curfews when required (i.e., Parole, Probation, etc.). Failure to return to the house on time can/will result in dismissal.
If you are diabetic or need to give yourself shots using a syringe, you will need to have a medical grade bin to dispose of used needles properly.
My signature signifies, I have read and understand what I can and cannot do while living in Claude’s House LLC. I understand and agree that if I break any rules within this document in red type, my stay will be terminated immediately, and I will be banned from living in other homes that Claude’s House LLC Housing manages.
Resident Signature: SignatureDate: Date