REFUGIO APPLICATION

MEMBERSHIP APPLICATION
1. COMPLETE APPLICATION AND SUBMIT FORM.
2. COMPLETE INTERVIEW WITH HOUSE MANAGER.
3. IF ACCEPTED, ARRANGE TIME AND DATE OF ARRIVAL.
Please note: An acceptance letter will be issued only after the completion of the above process.
Disposition
To be filled out by staff only
Weekly Rate*
This is the rate to be charged and can be changed by Admin only prior to Approval of application
Actual Move-in Date

MonthDay Year
Actual Move-out Date

MonthDay Year
NAME*
First and last name as shown on government ID
DATE OF BIRTH*

MonthDay Year
Date
Sex on Government Issued ID*

MaleFemale
Previous / Permanent Address*
City*
State*
Zip*
Driver License / State ID #*
State Issuing ID*
Social Security #*
XXX-XX-XXXX
Take a photo of your Driver License / ID / Passport
Take a photo of yourself.
Your Phone #*
Your Email*
example@example.com
Emergency Contact Name*
CONTACT PHONE #*
Relationship to You*
Wife, mother, brother, sister, friend, etc.
CONTACT EMAIL*
example@example.com
CONTACT ADDRESS*
CONTACT CITY*
CONTACT STATE*
CONTACT ZIP*
Date you last used drugs or alcohol*

MonthDay Year
Date
Drug(s) of Choice*
Where are you now?

Drug and Alcohol TreatmentIncarceratedLiving with Family or FriendsLiving AloneHomeless
Name of Treatment Center and Counselor's or Case Manager's Name and Email
If you are presently in treatment for alcohol or drugs, Please list the facility and the name of the person that assists with your treatment and discharge.
How did you find out about Refugio House?

GoogleYelpOther WebsiteTreatment Counselor / Case ManagerProbation / CPS / CourtFamily or FriendMy LawyerOther
Which 12 step meetings do you attend? (AA, NA, CA, CR, etc)
Sponsor Name
Sponsor Phone #
List Medical Conditions.
List Prescription Medications.
Failure to list every medicine brought into house will result in immediate expulsion without refund of money paid.
Have you ever lived in a sober living home?*
Yes or No
If yes, which one?
Have you engaged in any of the following self-harming behaviors in the past year?

Thoughts of SuicideCuttingBurningHair Pulling
Have you ever been diagnosed or treated for an eating disorder?

YesNo
Are you involved in any legal action?*
Yes or No
If "Yes" please explain
Are you required to register as a sex offender?*
Sex offenders are ineligible for our program. If you answered yes, we will refer you to another agency.
Have you ever been charged or convicted of arson?*
Persons with a history of an arson conviction will be referred to another agency.
List all felony convictions and dates including state jail felonies no matter how old. *
We will carefully consider the type, severity, and time elapsed since any felony conviction.
Are you on probation or parole?*
Refugio is not a halfway house. It is transitional sober living for addicts and alcoholics serious about recovery. You must be established in the local community in some way prior to entering our house.
Are you employed or in school? Where?*
What is your weekly income and source of income?*
Requested Move in Date*

MonthDay Year
Date
Are you entering our house on Medication Assisted Treatment?
Doctor Info
Enter name, address and telephone of your prescribing doctor or provider. If you are on MAT, within seven days of move in you must provide Refugio House with a copy of a signed HIPAA release from your doctor that will allow us to speak with your doctor about your MAT medications, have access to appointment schedules, prescription lists, and general progress information. The HIPAA release can be obtained at your doctor’s office.
Are you bringing a vehicle? (No dual wheel trucks, trailers, or commercial vehicles. Vehicle must be legal to drive. No vehicle repairs allowed on property)*

CarTruckMotorcycleI don’t have a vehicle.
IMPORTANT LEGAL NOTICE
Refugio House is a recovery home which requires expulsion, without prior notice or refund of deposit and fees, of any resident member who is found to be: 1) using alcohol or drugs; 2) engaging in disruptive behavior; or 3) in default of payment of weekly membership fee. All residents of Refugio House are members of our recovery home. You do NOT have renter's rights or any rights of tenants pursuant to the Texas Property Code, and expressly waive any such rights in exchange for membership privileges.

I have read the above notice and understand that I am applying for membership of Refugio House as a member of a recovery home. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules of the home, which include periodic random drug and alcohol testing. I understand that I am subject to immediate expulsion from the home if any of the following occur: 1) I use alcohol or drugs (other than prescribed medications); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior); 3) I fail to pay my weekly membership dues. I understand that my deposit and member fees will not be refunded in these circumstances or if I voluntarily leave the house; 4) I agree to give a thirty day notice in the event I choose to leave the house voluntarily and will be responsible for any charges incurred during that period for failing to give notice or if I am expelled for house rules violation.

By signing below, I certify that the information contained in this application is true. I have read and understand the Refugio House rules and policies. I understand and accept the above conditions set forth for membership in Refugio House and agree to abide by said conditions should I be selected as a member resident.
SIGNATURE of APPLICANT*

Clear
DATE*

MonthDay Year
Date
I have received a copy of the house rules and policies. I understand that failure to follow the rules and/or responsibilities may result in monetary fines and/or expulsion from Refugio House. In the event of expulsion, I understand that any fees/deposits paid to the house will not be refunded and that any future fees may be accelerated and made due immediately.

I further understand and consent to security camera audio and video recording 24 hours a day on Refugio House property that is considered to be a common area. Bathrooms and Bedrooms are exempted from video recording. I agree to always be fully clothed when in view of a camera and release Refugio House and Ted Hunt Properties LLC, its owners, employees, contractors, and assigns from all legal or civil liability if I fail to do so. All calls made or received from Refugio House phones are recorded. I consent to such recording.
NAME of RESIDENT MEMBER*
SIGNATURE*

Clear
DATE*

MonthDay Year
Date
Please verify that you are human*
When You Press Submit
When you submit this application you will automatically be forwarded to the Clean Cause Foundation website to apply for a $500 sober living scholarship. Scholarships are awarded based upon need and funds availability. There is no guarantee. Payment of deposit and first week in advance is required by Refugio House prior to move in.
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MEMBERSHIP APPLICATION

IMPORTANT LEGAL NOTICE