Recovery Refuge Application
DATE: Date NAME: Client first nameClient last name DOB: Client birthdate AGE: Text field
PHONE NUMBER: Client phone EMAIL: Client email
FAMILY CONTACT AND PHONE NUMBER:
1. Name: Text field Phone number: Text field
2. Name: Text field Phone number: Text field
3. Name: Text field Phone number: Text field
4. Name: Text field Phone number: Text field
DO YOU HAVE A RELATIONSHIP WITH JESUS? Text field
WRITE A BRIEF SUMMARY OF YOUR TESTIMONY:
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WHAT DRUG OR ADDICTIONS HAVE YOU STRUGGLED WITH THE MOST?
Client substances of choice
HOW OFTEN DO YOU OR DID YOU DRINK OR USE? Text field
WHY ARE YOU REACHING OUT FOR HELP AT THIS TIME?
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WHO REFERRED YOU TO US OR HOW DID YOU HEAR ABOUT THE PROGRAM?
Client Referred By
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ARE YOU IN A RELATIONSHIP?
Radio buttons
IF YES PLEASE EXPLAIN THE HISTORY:
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WHERE ARE YOU FROM? Text field
DO YOU HAVE ANY COURT CASES OR ON ANY TYPE OF PROBATION? PLEASE EXPLAIN IN THE NOTES SECTION BELOW.
Probation
ARE YOU PRESCRIBED ANY MEDICATION?
Radio buttons
IF YES, PLEASE LIST ALL MEDICATION:
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HAVE YOU EVER BEEN DIAGNOSED WITH BIPOLAR, DEPRESSION, PTSD, OR ANY OTHER DISORDERS BY A PHYSICIAN?
Client diagnosis
IF YES, PLEASE EXPLAIN:
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DO YOU HAVE HIV OR HEP-C?
Checkboxes
WHAT IS YOUR WORK HISTORY?
EmploymentHistory
ARE YOU ABLE TO WORK IN A HOT ENVIROMENT?
Radio buttons
ARE YOU ABLE TO LIFT OVER 40LBS ?
Radio buttons
DO YOU HAVE ANY PHYSICAL LIMITATIONS?
Radio buttons
IF YES, PLEASE EXPLAIN:
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This agreement is between, Text field (resident/client) and manager; and/or owners and founders of Recovery Refuge.. Resident Agrees to voluntarily participate and reside in the recovery environment/home at 1950 Carver Drive Greenbrier, TN 37073.
This agreement is a recommended 7 month term effective Text field to Text field. This agreement maybe renewed or amended if agreed on and approved by management; and/or owners and founders of Recovery Refuge.
Resident print name: Text field
Resident Signature: Signature Date: Date
Witness Signature: Signature Date: Date
Personal Information
Prior Address: Text field
Name: Text fieldText field
Phone: Text field
Marital Status: Client marital status
DOB: Text field
Spouse Name: Text field
DOC: Text field
Emergency Contact
Contact
I Text field give Recovery Refuge permission and consent to contact my emergency contact, in case of emergency.
Date of Arrival: Date
Are you currently on probation or parole? Text field
Probation Officer Name: Text field PO Phone #: Text field
I Text field give consent to Recovery Refuge to contact and to be contacted my probation officer.
Do you have any outstanding warrants and/or any pending charges?
Radio buttons
If yes, explain:
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Resident Signature: Signature Date: Date
Witness Signature: Signature Date: Date
Medication Management Policy
All residents at recovery refuge are required to disclose if he is prescribed any form of medication. NO narcotics, medication administration treatment plans or any mood-altering chemicals will be allowed on the premises. All prescribed medications must be documented with recovery refuge. Prescribed medications approved by recovery refuge must be kept in a self-provided lock box and kept locked. Changes in prescribed medications must be reported. If you experience any difficulty with these medications, please notify recovery refuge and we will work together to find a solution.
All over the counter medicines must be reported, approved, and documented with recovery refuge while living in the home.
Initials Text field I commit to not sharing any OTC and prescribed medications with other clients of the house.
Initials Text field I commit to only having approved OTC and prescribed medicines on the property of recovery refuge.
Initials Text field I commit to keeping all approved medicines locked up in a self-provided lockbox.
Initials Text field I commit to no narcotics, medication administration treatment plans, mood altering chemicals, or mood-altering substances here at recovery refuge home at any time.
Initials Text field Consents to recovery refuge to contact my doctors and my doctors to contact us regarding prescribed medications.
Medication
Resident Signature: Signature Date: Date
Witness Signature: Signature Date: Date
Name: Text field
Initials Text field I commit to abstain from the use of all mood- or mind-altering substances.
Initials Text field I commit to and agree to attend Church services at Long Hollow Church on Sundays.
Initials Text field I commit to and agree to attend Celebrate Recovery on Monday nights at Long Hollow Church.
Initials Text field I commit to and agree to attend the weekly Celebrate Recovery step study offered by Recovery Refuge volunteers/staff.
Initials Text field I commit to and agree to attend the weekly men’s bible group taught by Recovery Refuge staff/volunteers.
Initials Text field I commit to and agree to attending 5 weekly recovery based meetings.
Initials Text field I commit to and agree to abiding by the weekly schedule set by Recovery Refuge staff.
Initials Text field I am willing to discuss any of my concerns and issues with Recovery Refuge staff.
Initials Text field I understand and commit to not abuse energy drinks or any other food or beverage containing high levels of caffeine, taurine, or ginseng in the house or on the property.
Initials Text field I am willing and agree to not use tobacco products inside the house. Recovery Refuge has notified me of where smoking is permitted.
Initials Text field I am willing and agree to not use Kratom, unprescribed testosterone or any other over the counter synthetic drugs.
Initials Text field I understand and agree to not have any pet of any kind in the house or on the premises.
Initials Text field I commit to obtaining a sponsor within four weeks of joining the recovery refuge community and actively maintain a working relationship with that sponsor for the duration of my stay at recovery refuge.
Initials Text field I commit to attend all house meetings. I understand that in case of an emergency I am to notify recovery refuge and the community immediately.
Initials Text field I understand that until I have secured employment I am to be out of the house by 8am applying for jobs until employment is obtain.
Initials Text field I understand that I live in a community and in respect I will not cause, allow participate in activities that might disturb the peace and quiet of other residents.
I agree to all the following curfews:
0-30 days of residency—10:00 pm Every day of the week.
31-90 days of residency—10:00pm Sunday-Thursday and 12:00 Midnight Friday and Saturday
Over 90 days of residency—12:00 Midnight- Sunday-Thursday and 1:00 am Friday and Saturday.
These curfew provisions may be modified.
Individual situations can be brought to staff and community.
Initials Text field I understand that after 40 days of residency, I may request permission for an overnight pass.
Initials Text field I will provide 24 hours advance notice. Requesting exceptions of curfew must receive advance approval from Recovery Refuge.
Initials Text field I understand that no visitors are permitted on the premises of recovery refuge. Special consideration can be discussed with staff and community within 24 hours in advance of the arrival of any such visitors.
Initials Text field I understand that theft is not Recovery Behavior.
Initials Text field I commit to not open or tamper with mail or packages that do not belong to myself.
Initials Text field I commit to not possess any firearms or weapons of any kind.
Initials Text field I agree to not store or consume any food or drinks in the bedrooms of recovery refuge.
Initials Text field I agree to perform daily/weekly chores as assigned and directed by recovery refuge and the community within.
Initials Text field I agree to no flushing anything other than toilet paper down the toilets.
Initials Text field I agree that any damage done to property or residence of recovery refuge will fall on responsible parties.
Initials Text field I agree to immediately dispose of any waste products, including but not limited to bottles, food wrappers or containers, junk mail, packaging material, dirty dishes, cups, utensils, etc. in the common areas and rooms of recovery refuge will result in additional chores (Accountability Chores).
Initials Text field I agree my room is to be kept cleaned and beds are to be made when not being utilized.
Initials Text field I understand that we live in a neighborhood I will turn my music down before I turn onto Carver Drive, out of respect for my neighbors.
Initials Text field I agree to treat other residents and the staff at recovery refuge with respect, and if I violate, I understand that a community meeting will be held to discuss a solution immediately.
Initials Text field I am aware that violence is not safe for myself or others. I understand that if initiate or participate in violet or negative behavior, a community meeting will be held to discuss a solution immediately.
Initials Text field I understand that when I leave recovery refuge, that I have 10 days to remove all my belongings, and if they are not off the property within 10 days that they will be removed accordingly.
Initials Text field I commit to have no drug paraphernalia on the property of recovery refuge at any time
Initials Text field I am aware. “There is always a solution.” A Community meeting can be requested. Discussion with Staff is suggested.
Initials Text field I agree and understand that residence at recovery refuge is pursuant to Tennessee Code Annotated 66-28-102 (c)(1), which states residence at an institution, public or private if incidental to detention or the provision of medical, geriatric, educational, counseling, religious, or similar service is not subject to the provisions of the Uniform Residential Landlord and Tenant Act of Tennessee. In other words, this agreement is not a lease and notice are not required by Recovery Refuge to discharge a Resident for violation of institution guidelines. --
Resident Name: Text field Date: Date
Witness Signature: Signature Date: Date
Witness Name: Text field Date: Date
Witness Signature:Signature Date: Date
Financial Transparency Agreement:
Date: Date
- The first two week’s payment and entry fee ($175/wk) total $350.00 and application fee ($100) for a total of $450 must be paid before resident moves in, and the continued $175 per week will be due thereafter. Residents also have the option of paying $225 a week until the $450 is paid off.
Initial: Initials Text field I understand that I will be responsible to pay $175 per week for the duration of my stay at Recovery Refuge.
Absolutely NO REFUNDS will be given if a resident leaves Recovery Refuge
Initial: Initials Text field I understand that Recovery Refuge will not give any refunds.
Recovery Refuge will provide basic cleaning supplies such as disinfecting wipes, dish washing detergent, hand soap, dish soap, and dish sponges. Recovery Refuge will provide paper towels, toilet paper, drug tests, and a breathalyzer.
Residents will be required to provide all personal hygiene products such as toothbrushes, toothpaste, deodorant, body wash, shampoo, conditioner, high efficiency laundry detergent, and any other personal care product that the resident desires.
Initial: Initials Text field I understand that I am responsible for all personal hygiene products, as well as high efficiency laundry detergent.
Resident Name: Text field
Resident Signature: Signature
Entree Fee: Text field
Witness Signature: Signature
Drug Testing Policy:
Recovery Refuge is a 100% drug and alcohol-free residence.
Any use of any mind-altering substance will require intervention by staff and community.
Initial: Initials Text field I understand that no form of mind- or mood-altering substances are allowed at Recovery Refuge.
- I understand and agree that I have been free of any mind-altering substances for at least 168 hours before my arrival at Recovery Refuge.
- I am willing to be drug and alcohol tested upon my entrance to Recovery Refuge
- I commit to and am willing to be drug tested randomly during my stay at Recovery Refuge.
- I understand and agree that a Refusal to take a drug test immediately may result in me being asked to make a change in my living environment.
- I understand and agree that if my drug test yields questionable results, I have the opportunity to take a lab test at my own expense.
Initial: Initials Text field I understand that I will be randomly drug tested and breathalyzed at Recovery Refuge.
Witness Signature: Signature
Date: Date