CLAUDE'S HOUSE
Move-In form
Getting Started: Your Path to Stability Begins Here!
Our Interview & Move-in Process.
Step 1: Submit a Lead: Intake Form
Step 2: Initial Review by Claude's House Team
Step 3: Phone/Video Interview & Screening with Resident
Step 4: Acceptance Decision
Step 5: Pre Move-In Coordination
Step 6: Move-In Day
⚠️ Please note: This house is not handicap accessible.
Residents must be able to care for themselves. We do not provide personal care or supervision.
Click next to begin!
Resident - General Information
Tell us about yourself
First Name:Client first name
Middle Name: Client middle name
Last Name:Client last name
Date of Birth:Text field
What is your race/ethnicity?Client race
What is your gender?Client gender
What is your marital status?Client marital status
Are you a veteran?Client veteran
Insurance
Enter your insurance provider(s).
Insurance
Living Situation
Current Living Situation:
LivingArrangementHistory
Do you have children? (Required Response) Checkboxes
If yes, is DCF involved? Checkboxes
If yes, please explain: Text field
Have you lived in a shared, sober, or structured home before? (Required Response) Checkboxes
If yes, what was your experience like? Text field
Recovery & Substance Use
Have you ever lived in a sober or recovery home?(Required Response) Checkboxes
If yes, list name, length of stay, and reason for leaving:Text field
Have you attended a treatment or recovery program? (Required Response) Checkboxes
If yes, list name, length of stay, and reason for leaving:Text field
How long have you been sober? Text field
Substance(s) of Choice: (Required Response)Client substances of choice
Are there triggers or stressful situations that may challenge your recovery?(Required Response)Text field
Are you willing to participate in required and random drug/alcohol testing?(Required Response) Checkboxes
Mental Health & Medical Information
Have you ever been diagnosed with any mental health conditions? (Required Response)Checkboxes
If yes, please explain Text field
Do you have any ongoing medical conditions or health concerns? Client health problems
Do you have regular medical or behavioral health appointments? Checkboxes
If yes, please explain: Text field
Allergies (if none, skip): Client allergies
Do you use any medical equipment? (Check all that apply)(Required Response) Checkboxes
Checkboxes Cane Checkboxes Walker Checkboxes Other: Text field
Medications
List the medications you are currently prescribed.
Initials Text field IMPORTANT: Medication lockboxes are required prior to move-in. (Required Response)
Are you currently prescribed any medications or MAT? (Required Response) Checkboxes
List all prescribed medications:
Medication
Legal & Safety Information
Are you currently on probation or parole? (Required Response) Checkboxes
If yes, supervising county/officer: Text field
Do you have any open or pending legal cases or charges? (Required Response) Checkboxes
If yes, explain (include county): Text field
Do you have any history of violence or aggressive behavior? (Required Response) Checkboxes
Are you a member of or affiliated with any gang? (Required Response) Checkboxes
Resident Suitability Questionnaire
Claude’s House is not an assisted living facility, nursing home, or medical provider.
Residents must be able to care for themselves independently, including personal hygiene, meals, and mobility.
⚠️ This home is not wheelchair accessible.
Initials Text field I understand and acknowledge the information above. (Required Response)
Can you participate in household cleaning and chores? (Required Response) Checkboxes
Do you smoke tabacoo cigarettes? (Required Response) Checkboxes
List ANYTHING else we should be concerned about. Text field
Client Referral Source
Who referred you to Claude’s House? Text field
Anticipated Move-In Date
Estimated Move-In Date? (Required Response) Text field
Fees & Payment
I have read and understood the below.
(Required Response)
Initials Text field Move-in fee: $200 (non-refundable) if not on scholarship or third-party support
Initials Text field Weekly fee: $225
Initials Text field Partial weeks prorated: $32/day
Initials Text field Payments due weekly on Fridays (unless arranged for scholarship/funding)
Initials Text field 30-day notice required for prorated refund of advance payments
Work, Income & Daily Structure
Claude’s House is a working house.
Initials Text fieldResidents are expected to work, volunteer, attend school, or participate in approved daily programming. (Required Response)
Exceptions: Residents receiving SSI/SSDI or with documented disabilities may be exempt from employment requirements; however, participation in structured accountability (programs, groups, or activities) is still required and strictly enforced if capable.
Checkboxes Employed Checkboxes Volunteering Checkboxes In School Checkboxes In Program Checkboxes SSI/SSDI Checkboxes Unemployed
EmploymentHistory
Living Situation
Current Living Situation:
LivingArrangementHistory(Required Response)
Do you have children? (Required Response) Checkboxes
If yes, is DCF involved? (Required Response) Checkboxes
If yes, please explain: Text field
Have you lived in a shared, sober, or structured home before?(Required Response) Checkboxes
If yes, what was your experience like? Text field
Additional Information
Please list anything else we should be aware of when reviewing your application: Text field
House Rules
Zero-Tolerance
No weapons, illegal drugs, drug paraphernalia, or alcohol on or around the property
No violent, aggressive, or threatening behavior
No sharing, selling, or storing another person’s medication
No entering another resident’s bedroom
No romantic or sexual advances toward residents or staff
Safety & Security
Entry and exit doors must remain closed and locked
Smoking in the back of the home (back patio only)
Report and clean spills immediately
Do not leave items on floors that may cause trip or slip hazards
Residents must check in nightly
Substance-Free Expectations
Smoking in backyard only
No alcohol anywhere on premises
Random drug/alcohol testing for all residents
Testing required after overnight passes or extended trips
House Conduct
Claude’s House is a working house; participation in work, school, volunteering, or approved programs is required
Exceptions only for SSI/SSDI or documented disabilityDo not steal or misuse others’ belongings
Clothing must be worn outside bedrooms
No personal items unattended in common areas
Residents may enter/exit 6:00 AM – 12:00 AM
Cleanliness & Chores
No food in bedrooms
Clean shared spaces immediately
Rooms kept clean and orderly
Complete assigned chores as directed
Bedrooms & Personal Space
Mattress covers must never be removed
Keep bedroom doors closed
Secure personal/valuable items
Rooms may be inspected/search by management
Hygiene & Health
Maintain personal hygiene
Properly dispose of diapers or hygiene items
Medical sharps require approved disposal containers
Laundry
Use laundry only on assigned days/times
Do not wash another resident’s clothes
No feces-soiled items may be washed in house machines
Guests & Overnight Passes
No guests inside home
Overnight passes require approval after adjustment to home
Meetings
Weekly mandatory house meetings
Discuss house concerns, grievances, expectations, and successes
We are a peer led working home!
Groups/meetings/programs are mandatory!
I have read and understood it is my responsibility to comply with the rules on this document. (Required Response)Initials Text field
Resident Signature: SignatureDate: Date