Name *

First Name

Last Name

Home Phone *

(###)

###

####

Mobile Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Gender (at birth) *

Male

Female

Marital Status *

Single

Married

Divorced

Widowed

Are you currently in a relationship? *

Yes

No

Partner/Spouse Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have a valid driver's license? *

Check yes only if you have you it in your possession.

Yes

No

Do you have a valid social security card? *

Check yes only if you have you it in your possession.

Yes

No

Do you have a valid birth certificate? *

Check yes only if you have you it in your possession.

Yes

No

Referral Phone *

Phone number of person who referred you to Our House of Restoration.

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Are you ordered to pay child support? *

Yes

No

Are your child support payments up to date? *

Yes

No

N/A

Do you have an open DFCS case? *

Yes

No

Are you able to contact or visit your children? *

Yes

No

N/A

Reference #1 *

First Name

Last Name

Reference #1 Phone *

(###)

###

####

Reference #2 *

First Name

Last Name

Reference #2 Phone *

(###)

###

####

Are you an IV drug user? *

Yes

No

Any clean time *

Yes

No

Any previous treatment? *

Yes

No

Did you complete this program? *

Yes

No

Is there an outstanding balance from your previous treatment facility/program? *

Yes

No

N/A

Are you willing to pay the balance? *

Yes

No

N/A

Are you homeless? *

Yes

No

Any childhood trauma? *

Yes

No

Do you have a healthy support system? *

Yes

No

Do you have: *

Private insurance

Medicare

Medicaid

None of the above

Do you have a mental health diagnosis? *

Yes

No

Do you have a medical supply? *

Yes

No

Have you ever been admitted into a mental health facility? *

Yes

No

Have you ever attempted suicide? *

Yes

No

Are you now or have you ever been a cutter? *

Yes

No

Are you currently using medically assisted treatment (Suboxone, subsoil, Methadone, etc.)? *

Yes

No

Do you have any physical conditions that require special equipment or that interfere with day to day functioning? *

Yes

No

Do you have unprotected sex or at high risk for HIV? *

Yes

No

Have you tested positive for AIDS? *

Yes

No

Have you tested positive for Hep C? *

Yes

No

Are you pregnant? *

Yes

No

Do you currently have a church you attend? *

Yes

No

Are you a convicted felon? *

Yes

No

Do you have drug charges that exempt you from government assistance? *

Yes

No

Are you currently on probation? *

Yes

No

If so, is permission needed? *

Yes

No

N/A

Any previous sex crime convictions? *

Yes

No

Do you have any outstanding legal matter(s)? *

Yes

No

Checking the box serves as your digital initial/signature. *

If you make a decision to leave the property or are discharged you are responsible for removing all of your personal belongings. Items not removed will be considered abandoned. You have 24-48 hours to collect your belongings; items not taken are forfeited by you.

You will agree to take job opportunities within reason.

You will volunteer up to 10 hours per week if not employed, during your stay at Our House of Restoration.

You will fulfill daily household obligations assigned to you.

You will attend all church services.

You will abide by parole and probation requirements set forth by these offices (sign consent form).

You agree to pay rent on time. Failure to do so could lead to being discharged: (People actively seeking employment will be handled on an individual basis).

You agree to pay $350.00 deposit (nonrefundable): (method of payment check or money order).

You agree to pay $175.00 weekly (failure to pay will result in discharge).

You agree to complete all courses in our program in the time frames required.

You agree to a mental health assessment and to follow any treatment plan set forth by the mental health agency or counselor.

You are aware that we administer random drug and or alcohol screenings and room searches.

You agree to be responsible for all your medical needs while living at Our House of Restoration.

You agree to a 30-day probationary period upon full admission into the program.

You will attend (4) 12 step/spiritual/wellness meetings per week unless otherwise determined by the director.

You agree to be supportive and encouraging to your sisters in the Our House of Restoration program.

You understand that you can be discharged, with no refund, if you are repeatedly uncooperative, have a bad attitude, do not follow directives, break house rules or policies, fail to apply yourself, abuse your nap time and/or fail to fulfill assignments.

Disciplinary actions are decided based on the level of the violation which can include; verbal warning, written warning (P.O. will be notified) a behavioral contract or immediate discharge. Noncompliance of a behavioral contract can lead to an immediate discharge.

You understand that drugs/alcohol/paraphernalia found in your personal property/person or positive drug screen will result in an immediate discharge.

You agree to have no outside contact for 30 days (blackout period) unless given permission.

You understand the first 30 days are a probationary period. You can be discharged during this time for any undisclosed reason.

Date

MM

DD

YYYY