HH Recovery Application

HH Recovery Application Mar 2019
APPLICANT INFORMATION
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Marital Status *
EMERGENCY CONTACT INFORMATION
Name *
Relationship *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
How did you hear about Hope House?
BACKGROUND
Do you have any felonies? *

Yes No
If YES, please explain.
Have you ever been accused of, participated in, or been convicted of a sexual crime and/or a violent crime with either a minor or adult? *

Yes No
If YES, please explain.
Are you on probation or parole? *

Yes No
If YES, Termination date:

Month Day Year
Date Date Picker Icon
Officer's Name
Officer's Contact Number

Area Code Phone Number
Are you court-ordered to attend a drug/alcohol program? *

Yes No
Do you have any upcoming court dates? If YES, when?
Do you have any outstanding charges? *

Yes No
If YES, specify charges.
Do you have any child support obligations? *

Yes No
If YES, specify.
SUBSTANCE ABUSE HISTORY
What is/was your drug of addiction? *
How long have/had you been using? *
How long have you been sober? *
When is the last time you used? *
Name the program(s) and date(s) of your treatment:
MEDICAL HISTORY
Do you have any disease or medical condition that would hinder or prevent treatment in this program? *

Yes No
If YES, please explain.
Do you have any mental or psychiatric issues? *

Yes No
If YES, explain, including whether or not they are diagnosed and documented:
Please explain your current medical condition or any medical issues:
PHYSICAL HEALTH INFORMATION
How would you rate your physical health? *

Good Fair Poor
Do you currently have any physical disabilities? *

Yes No
If YES, please explain.
Do you have any long-term physical or other limitations that affect your daily living? *

Yes No
If YES, please explain.
If you have any physical limitations that would prevent you from any of following, select which ones. *

Working on equipment (e.g. printing press) Manual labor (e.g. cleaning, landscaping, etc) Climbing stairs in a 2-story home Exercising Participating in fundraising activities Not applicable
If YES, to any of the above, please explain:
List of allergies, including drug allergies.

List all prescriptions for diagnosed illnesses (physical & mental):

	Illness	Medication	Prescribing Physician	Rx Needed
1.
2.
3.
4.
5.

Check any of the following that apply to you:

Dizziness Stomach trouble Unable to relax Trouble making friends Depressed Heart palpitations Pregnant Fainting Spells Insomnia Alcoholism Drugs Headaches Hepatitis C High Blood Pressure Feel tense/panic Suicidal thoughs Feel lonely Can't keep a job Shy around others HIV/AIDS Diabetes
WORK/SKILL HISTORY ASSESSMENT
Are you currently employed? *

Yes No
If YES, provide name and address of employer:
Past or present work occupations: *
Work interests or skills: *
Last grade or year of schooling completed: *
Diploma/Degree earned:
FUTURE ASSESSMENT
What do you enjoy doing in your free time? *
How do you feel about yourself today? *
What are some short-term goals that you would like to accomplish in the near future? *
Describe your perception of God. *
What is your support system (spouse, family, friends, sponsor, etc)? *
List all individuals that may be interested in supporting your stay (emotionally, financially) at Hope House.
1.
Name

First Name Last Name
Relationship
Emotional support

Yes No
Financial support

Yes No

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
2.
Name

First Name Last Name
Relationship
Emotional support

Yes No
Financial support

Yes No

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
3.
Name

First Name Last Name
Relationship
Emotional support

Yes No
Financial support

Yes No

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
RESOURCES
Monthly household income *
Describe income source *

Other income

	Amount
Food stamps
Medicare
Disability
Medicaid
SSI

Mark any current insurance coverage

Indigent Healthcare
If YES, provide below information:
Insurance Company Name
Policy Number
Name of Insured
Claims Phone Number
Upload a copy of your insurance card, if available:

Browse Files

Cancel of
PROGRAM CONDITIONS:
Please read all of the below statements and check the box next to each item if you agree. *

I understand that Hope House is a Christian-focused program, and that all residents must desire to keep it a safe and loving place. Hope House is a place for our residents to foster a sense of community, to thrive, to change, and to implement real steps that lead to a restored life. There will be zero tolerance for alcohol/drug use or disrespect of management/staff, other residents, or volunteers. A poor attitude, profanity, discrimination, bullying, physical or verbal confrontation will not be tolerated. Residents must obey authority unless illegal, immoral, unethical, or unsafe. All residents will be on a 30-day probationary period. I am ready to turn from my addictive lifestyle and desire to be healed by the saving power of Jesus Christ. I will strive to set a good example for others. I will exercise self control and show genuine kindness and respect toward other residents, persons in authority, and the general public in my words, attitudes, and actions. I understand that Hope House is a med-free environment (narcotics, pain meds, medication for anxiety/depress). Residents may purchase Ibuprofen. Medical conditions and/or injuries must be brought to management's attention. Use of any prescribed medication (e.g. antibiotics) must be approved by the Program Director. Residents must have a current medical physical and TB test completed by Hope House's designated physician. I understand that residents are requested to pay the $300.00 monthly fee by the 1st of each month. Scholarships may be available. I agree that if I am able to pay my support, I will do so. This includes regular monthly income as well as 80% of my food stamps (if eligible). I understand that Hope House RECOVERY is a closed campus program. Residents are not allowed to leave premises or events without advance approval of the Hope House Program Director. I understand that, once eligible, I must follow phone usage and visitor/guest processes (see procedures and house rules for times). I understand that all residents must attend the required church services, classes, and fundraising and mission service activities. I am willing to participate in classes, ministry activities, including working in the t-shirt business shop, general labor (cleaning/landscaping/etc.), serving the homeless and fundraising. Residents must be respectful of Hope House leaders – do not leave/vape during class. Residents must apply for financial resources if eligible (e.g. food stamps, indigent care). Residents are responsible for their own personal items. Residents will be taken on weekly shopping trips. I understand that all residents are accountable for the safety of the house. Residents must demonstrate honesty and trust and help create a safe and sober environment. Residents are expected to report to the Program Director any violations or concerns. Failure to do so, by any resident, will be cause for disciplinary action, including dismissal from the program. I understand that program concerns/comments should be discussed directly with the Program Director and/or put in the designated box in the office. I understand that all residents are expected to focus on their sobriety. I agree not to use any drugs or alcohol. I understand that I will be tested, and that if at any time I fail a test or refuse to be tested, I will be immediately dismissed from the program. I understand that my personal property is subject to searches while on Hope House property. I understand that my incoming/outgoing mail will be read/monitored. Each resident must take personal responsibility for Hope House property (house/room, grounds, and vehicles), by keeping them clean and orderly. I will take care of the property entrusted to me; I will daily make my bed and clean up my room, storing clothing appropriately. I will perform the chores as assigned. I will be responsible for my own laundry. I will only eat in the kitchen/dining areas and immediately clean up after myself. I will respect the property of others. I will not smoke in Hope House premises or vehicles; I will discard cigarette butts appropriately. I will use equipment and property properly. I will not bring any type of weapon on to Hope House property. No personal pets are allowed. Thermostats will be regulated by staff. I will turn off lights to conserve electricity. Candles/incense are not allowed. I will respect the property of others. I understand that using another’s property without permission will be considered stealing. I agree to comply with and follow all house rules (see ATTACHMENT A at bottom of application). I will not smoke inside Hope House premises or vehicles. I understand that vaping is only allowed during non-classroom and outside volunteer activities; vaping is not allowed during inside classes/activities or inside vehicles (Hope House/other). As a Christian household, all residents are expected to only have appropriate pictures/photos on the walls in their personal space. They must also only watch/listen/read to appropriate material (books, movies, programs/music). Music/TV/movie volume must be kept at a level respectful of others living in the house. Secular music is not allowed. Inappropriate subject matter includes R-rated, abuse, sex, drug, profanity. Residents must wear modest, clean clothing at all times. They must be fully dressed when downstairs. I understand it is against Hope House policy to borrow or lend to another resident or barter with another resident regardless of the situation. Gambling is not allowed. Hope House is not responsible for lost or missing items. I understand that items purchased by Hope House for general use may not be used for personal use. I understand that residency at Hope House is a privilege and not a right, and that at any time my conduct, progress, or cooperation with Hope House authorities is not in keeping with the program requirements, I will be disciplined, up to and including removal from the program.
I affirm that all information in this application is true and correct and that no effort has been made to deceive, hide, or neglect the transmittal of any information that is vital to the application process.
Type your name, to confirm you agree. *
Signature (this e-signature is binding confirmation). *

Clear
RELEASE OF INFORMATION

I give consent for the Program Director of Hope House or designee to release information about me or any member of my family to any organization that may have the ability to assist me in my current situation. Organizations include but are not limited to health care providers, health care facilities, parole or probation officer, workforce solutions, family crisis centers, MHMR, Department of Human Services, law enforcement, children’s advocacy center, CARTS and help assistance programs. I also give my consent for the organizations to release information to the Program Director of Hope House or designee. This release of information is for the above organizations and any other organization the Director may contact.
Signature (this e-signature is binding confirmation). *

Clear
MEDICAL TREATMENT, INFORMATION, AND RELEASE

In case of medical emergency, I hereby give consent to Hope House and/or their directors, officers, employees, representatives, and their agents to contact 911 and/or any medical professional on my behalf. I understand that I am responsible for any and all financial responsibilities that may occur. I understand that I should use my permanent address, not the Hope House address, on my medical claim forms.

I authorize Hope House to obtain and release my medical records. I also authorize my medical records to be released from my medical provider, hospital, clinic, doctor’s office or its staff to Hope House Ministry for induction and community living purposes.
Signature (this e-signature is binding confirmation). *

Clear
Property Retrieval

All residents who are removed or who exit from the Hope House program have 7 days from the date of discharge to schedule an appointment to retrieve personal property.

My signature acknowledges that in the event I am exited/removed, if I do not schedule an appointment AND retrieve my property within 7 days of my discharge date, the belongings will become the property of Hope House.
Signature (this e-signature is binding confirmation). *

Clear
HOPE HOUSE ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN HOPE HOUSE’s residential housing program, including any risks that may arise. I certify that I am physically/mentally fit and have not been advised to not participate by a qualified medical professional. I certify that there are no health related reasons or problems which preclude my participation in this program and its activities. I acknowledge that this “Accident Waiver and Release of Liability Form” will be used by Hope House, and that it will govern my actions and responsibilities while a participant of the program.

In consideration of my application/enrollment and permitting me to participate in this program, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including traveling to and from activities/events of this program, THE FOLLOWING ENTITIES OR PERSONS: Hope House, HOG Christian Ministries, and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers; (B)I INDEMNIFY, HOLD HARMLESS AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in any program event/activity, whether caused by negligence of release or otherwise. I acknowledge that Hope House, HOG Christian Ministries, and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors or omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Hope House. Risks may include, but not limited to, those caused by fundraising/production, terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people.

I understand that Hope House staff is not licensed or insured or professional medical staff; this is a pastoral ministry with assigned staff and volunteers. I hereby consent to receive medical treatment by a licensed provider in the event of injury, accident, and/or illness. I understand that any medical expenses incurred are my personal responsibility regardless if I have insurance; I agree to hold Hope House harmless from any liability for medical expenses incurred as a result of my residency. I understand that as part of this program, I may be photographed. I agree to allow my photo, video, film likeness and approved testimony to be used for any legitimate purpose by the program or designee.

The accident waiver and release of liability shall be construed broadly to provide release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.
Signature (this e-signature is binding confirmation). *

Clear
BACKGROUND INVESTIGATION CONSENT FORM

I hereby authorize Hope House and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal, or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained in my application and/or obtaining information, which may be material to my qualifications for residency, now and if applicable, during my tenure at Hope House.

I release Hope House and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or law suits in regards to the information obtained from any and all of the above referenced sources used.

The following is my true and complete legal name, and all information is true and correct to the best of my knowledge:
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date Date Picker Icon
Social Security Number
Maiden name or other names used
List all addresses of places you have lived the past 7 years and the years you lived there.

Current Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Dates lived there *

Former Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Dates lived there

Former Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Dates lived there
If more, list the address and dates lived below:

List all places where criminal charges have been filed, regardless of outcome.

	City, State	Offense	Year
1.
2.
3.
4.

Driver's License Number *
State of license *
Is your driver's license valid? *

Yes No
Signature (this e-signature is binding confirmation). *

Clear
ATTACHMENT A - RECOVERY RESIDENTS: HOUSE RULES

Arise at times to be determined by weekly schedule.

Be in bed with lights out by 10 PM with the exception of Fridays and Saturdays when lights-out is 11 AM.

Obey authority (e.g. Program Director, House Manager, Resident Assistant) unless illegal, unethical, or unsafe.

Be courteous to other”s as you would like them to be courteous to you. Have an attitude of gratitude. Be respectful of others; be flexible, cooperative, and sensitive to the needs of others instead of insisting on your own way.

Support and encourage each other in words and actions. Speak only appropriate and uplifting language/words. (No profanity, harassment, discrimination, bullying)

Attempt to resolve conflicts with other residents in a Biblical manner. Bring unresolved concerns to the attention of the Program Director instead of discussing with other residents.

Discuss staff/volunteer concerns with the Program Director (not with other residents).

Attend and participate in all studies, meetings and classes. Be respectful of teachers/Promise Leader. Do not leave class or activity unless emergency.

Attend Wednesday and weekend church services.

Stay on Hope House property/premises unless approved otherwise.

No food or drink is allowed upstairs, except water.

Keep kitchen (e.g. microwave, refrigerator, counters), dining, living areas and bathrooms clean.

Pick up after yourself – immediately.

Immediately wash personal dishes using hot, soapy water; dry and put up in appropriate place.

Perform assigned chores daily – Must be finished before any other activity can begin (except for devotions).

Keep personal space clean; make beds before leaving your room; store clothing appropriately. No candles/incense.

Post only appropriate pictures/photos on personal space walls.

Keep property grounds neat and clean.

Conserve energy – turn off lights/appliances. Thermostats will be regulated by staff only.

Wear modest, clean clothing at all times. Must be fully dressed when downstairs.

Maintain good hygiene and personal cleanliness at all times - daily bathing, shaving, deodorant, hair and personal grooming. Notify Program Director of personal items needs to be bought weekly.

Do personal laundry during assigned times.

Sleep only in personal space – not in living areas.

Only enter another resident’s room upon approval.

Use your own property – clothing, personal items, etc. – Be respectful of others’ property. No gambling, loaning, or bartering.

Keep music/TV/movie volume at a level respectful of others living in the house during waking hours; head-phone music only during sleeping hours.

Listen to/watch only appropriate music/movies/shows. Read appropriate books/literature. (No secular music. Inappropriate subject matter includes R-rated, abuse, sex, drug, profanity)

Smoking and or vaping are only permitted in designated areas; discard cigarette butts appropriately.

Follow phone use process – Approval needed, limited to 15 minutes per resident.

Follow visitor process – Approval, public areas only.
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HH Recovery Application Mar 2019