Moving Forward Recovery House Resident Application for Level II Recovery Housing
Today’s Date: Date
The purpose of Moving Forward's Level II Recovery Housing is to allow individuals in recovery from substance use disorders to live in a peer supported environment free from alcohol and illicit drugs. Residents maintain accountability through drug screenings, tracking and documenting weekly recovery activities, as well as sharing in peer-run house meetings. All residents must participate in an outpatient clinical program that includes relapse prevention and employment readiness training. Moving Forward Recovery House Level II will be a staff monitored home providing staff and peer support to residents. All residents must have at least 30 days of recovery or successful completion of Level III recovery house. Residents must be able to have the ability to provide peer support to other residents, participate in recovery planning, and live in a housing environment with peer support and a house manager as opposed to a supervised treatment environment.
While living in Level II Recovery Housing, residents must:
● Maintain sobriety
● Be in services with a certified treatment facility
● Be actively involved in a qualified recovery plan
● Be willing to live in a congregate living arrangement
● Adhere to all Recovery Housing rules
The information requested herein, including that about sobriety, is NOT requested for purposes of discrimination or disqualification from housing, but for the purposes of including you for consideration.
Resident Name: Client first nameClient last name
Current Address:Client AddressClient CityClient StateClient Zip
Date of birth: Client birthdate Gender: Client gender
Race: Client race Ethnicity:Client ethnicity
Phone:Client phone
Email: Client email
Requested Date Housing will be Needed: Date
Do you have an addiction to alcohol and/or drugs? Dropdown
Date of last use: Date
Substance of choice: Client substances of choice
Are you currently receiving any clinical treatment for your addiction? Dropdown
If yes, where? Text field
Treatment provider contact:Text field Phone: Text field
(Note: All applicants must maintain a release of information document to MF for their service provider)
**Moving Forward does not accept anyone convicted of an arson or sex crime **
List Treatment History:TreatmentCenterHistory
Successful Completion: Dropdown
Sobriety Date: RecoveryHistory
(Note: qualifying candidates must have at least 30 consecutive days of verifiable sobriety to apply)
Mental Health Diagnosis: Client diagnosis
Please describe your Recovery Plan; LIST your sober support: Paragraph
Goals:
Paragraph
Medications you are currently prescribed:Medication
Health Issues:
Other: Text field
Allergies:Client allergies
Other:Text field
Please Select Answer:
Do you have any active warrants? Dropdown
Have you ever been convicted of a sex crime? Dropdown
Have you ever been convicted of an arson crime? Dropdown
Do you have any employment barriers? Dropdown
If Yes to any question above, Explain: Text field
Income:
Marital Status: Client marital status
Sources of Income: (Note: include any food assistance if applicable) Text field
*Residents are responsible for the purchase of their food*
Do you have a Food Assistance Card with active benefits? Dropdown
If Yes, what is the amount you receive monthly? Text field
If No, please explain: Text field
Total Monthly Income from Other Sources: Text field
How will you be paying your residential fees? Text field
Employment History: EmploymentHistory
Educaton History: EducationHistory
Residential Fee Schedule and Employment Expectations
Residential Fees - Below are the current weekly residential fees. Fees are due in full by Friday at 6:00 pm each week and to be paid via money order or cash, to the House Manager or through the First Step Payment Software. We will not take personal checks. Failure to pay fees may result in dismissal from Level II Recovery Housing.
0-14th day- $0-only applies if the resident is unemployed or not eligible for grant funding
1st- 6th Week - $30
7th- Week on- $50
Employment - It is Moving Forward's intent for all residents to find employment consistent with their recovery plan. Residents must have secure employment within 14 days of admission into Level II Recovery Housing for a minimum of 16 and maximum of 24 hours weekly, Failure to find and/or keep employment may result in dismissal from Housing. Residents must obtain a legal tax paying position and review the employment and position with the housing manager for approval of employment. If employment is not able to be gained within the 14-day period, the resident will have to show proof of attempt of gainful employment. The resident will be required to submit 7 resumes/applications per week and provide proof of doing so to the Housing Manager until employment is gained.
Employment Exception - Exceptions to the employment rule can be made for verifiable limitations, such as schooling and training. However, if an exception is allowed, residents are still expected to pay residential fees on time and continue approved community involvement activity to the limit they are able. If a resident is unable to work due to disability/social security, that resident will be required to participate in community service hours and events that will be agreed upon between the resident and house manager.
Vehicle
Do you have your own Vehicle? Dropdown
If YES, Do you have a valid License and Insurance? Dropdown
Probation/Parole
Do you have legal pending charges? Dropdown
Do you have a Parole/Probation Officer? Dropdown
Name and Contact Information for the above: Probation
Suggested Items Needed:
The following is a suggested list of items an individual would need when entering Level 2 Recovery Housing:
● Bed Linens - Comforter/Blanket, Fitted Sheet, Pillow, Pillowcase, hangers, hamper will be provided by Moving Forward recovery house. All linens/items must be left when the resident leaves the house.
● Personal Hygiene Products - Soap/ Body Wash, Shampoo, Deodorant, Shaving Cream, Razor, Toothbrush, Toothpaste. Towels and Washcloths will be provided but must be left when the resident leaves the house.
● Laundry Detergent
● Food/Meals - Because residents are responsible for providing their own food while in Level 2 Recovery Housing, you must have proof of food card or verifiable income.
● Transportation - Residents may be responsible for their own transportation at times. If a resident has a vehicle, they will need to comply with Moving Forward Recovery House guidelines.
● Clothing and Personal Items - Note: Storage space is limited in Recovery Housing. If it is determined that a resident has too many belongings suitable for their living space, residents will be asked to remove some items from their house.
By signing below, I certify that I have read all the material on this application form and have answered each question honestly and to the best of my ability. I am committed to living a sober/recovery-based lifestyle. I will uphold the rules as specified by Moving Forward Recovery House. I understand that I will need to leave immediately when asked, if I break any rule that may risk the health and safety of other residents.
Resident Signature: Signature Date: Date
Moving Forward Recovery House does not discriminate on the basis of race, ethnicity, age, color, religion, sex, national origin, disability, HIV infection whether asymptomatic or symptomatic, or AIDS.
Applications will be held for 30 days. If an applicant has not been placed at that time, they must re-apply to be eligible.
Applications will be processed based upon the date received. When space becomes available, Moving Forward Recovery House will attempt to contact the first applicant via personal phone number(s) and will give the applicant 24 hours to respond. If the applicant fails to respond at that time, we will assume the applicant does not desire Housing and will contact the next applicant.
Level II Emergency/Crisis Information:
During my residency, I understand that situations may arise involving a crisis. These situations may be a result of my own behavior or the behavior of other house residents. I understand that critical incidents are defined as incidents which involve an unforeseeable problem, issue, or crisis that include, but are not limited to:
● Intoxication/substance use
● A mental health episode that is more severe than the usual behavior of myself or others
● Vandalism, Destruction of property, Aggression/violence, Severe disrespect toward another person, Delusion/Hallucinations
If a situation occurs that is an emergency and there is an immediate threat to my health and safety or the health and safety of others, the appropriate emergency services may be contacted. If it becomes necessary, Moving Forward Recovery House staff or other residents may be required to contact law enforcement.
For a mental health or medical emergency, Call 9-1-1
In the event of an emergency, I give permission to have the following people contacted:
Emergency Contact Name and Number :Contact
In the event of a resident relapse, Moving Forward Recovery House will refer to the Relapse Policy. If the resident is exiting housing due to a relapse or other emergency scenario, such as dismissal for housing rules violation that put other residents at risk, list your action plan below: (include who you will call and where you will go)
Relapse:Paragraph
Discharge from Housing:Paragraph
Medical Emergency: Paragraph
I understand the emergency contact person listed above will be contacted in the event of an emergency
Resident Signature: Signature Date: Date