THIS IS NOT A LETTER OF ACCEPTANCE

THIS IS NOT A LETTER OF ACCEPTANCE
BUTTERFLY MOMENTS INC WOMENS RECOVERY CENTER
SENDAPPLICATION TO: 865 GRACEY AVENUE CLARKSVILLE TN 37040 OR BUTTERFLYMOMENTSINC@HOTMAIL.COM (EMAIL)

* Application must be filled out completely to be considered and be legible, please printi
Full Legal Name;
Address
Phone
M
Date

Month Day Year
Date
Other names/aliases, etc
Height
Weight
Birth Date

Month Day Year
Date
Referred by
Military Service; Yes-Date of enlistment
Date of enlistment

Month Day Year
Date
Please check all of the following forms of identification (ID) which you have in your possession

State Id Number Drivers License Social security card Number
Number/state
No Have you ever participated in an alcohol and/or drug treatment program? Yes Where Type option 3 Other
List all substances of abuse/addiction and the last date used for each

Month Day Year
Date
Substances
Are you court ordered to live in a half-way house?
Yes
Charge(s)

Felony Conviction: Yes No Yes-list Other
Do you have any legal charges pending now?
Yes

No if yes, list court date(s) and charge(s): Other
if yes, list court date(s) and charge(s):
Sex Offender: Yes

No Registered:
Registered
State of Registry
(A copy of probation/parole details must be provided) TOMIS #
TOMIS #
Probation/Parole Officer/IPO (if known)
Phone
Address
If incarcerated, what is your earliest projected release date: How long incarcerated

Who is your reentry counselor? Length of incarceration Release Date Other
Communicable Diseases
Other current illnesses
Prescription medications
Do you plan to or are you currently receiving (SSI) or disability income: Yes

NO if no, are you willing to work a minimum wage job: Yes
Upon acceptance to Butterfly Moments, a $200.00 nonrefundable deposit must be received before admittance *

Program Administration fee in advance: $200.00 plus First 2 weeks: $280.00 in advance (total $480.00): YesNo RHP Family Will Pay
Do you own a vehicle: Yes

No Do you have auto insurance: Yes No
Current Address & Phone Number (MUST PROVIDE THIS INFORMATION)
References Name/address
Release information to this person
Phone
Nearest relative Name/address
Phone
In the space provided, write a paragraph describing what you hope to achieve while at Butterfly Moments Inc
By signing below, I agree to abide by all House Rules with the full knowledge that willful failure to comply will result in my expulsion with loss of all deposits and/or prepaid fees. I agree that I will in no way hold the Owner/Director or occupants of Butterfly Moments Inc in any way responsible for any injuries or even death that may occur during my stay at said properties. I also give my consent for the House Owner/Director (or designate) to contact my family members, sponsor(s) and/or Probation/Parole Officer concerning my progress or welfare.
Signed

Clear
Date

Month Day Year
Date
Butterfly Moments Inc Women's Recovery Center

1. There is no application fee. If accepted, your final approval will begin upon receipt of nonrefundable $200.00 non-refundable program administration deposit and two weeks fee of

2. Fees are due each and every Friday. 3. Fees are $140.00 per week. 4. Fees can be paid up to four weeks in advance at a rate of $560.00 non-refundable. 5. If an individual becomes one week late on payments, she will be required to meet with the director for purposes of evaluating employment efforts and other pertinent financial responsibility matters. 6. Any fees paid in advance will be forfeited if you move or violate rules resulting in discharge. 7. Program participants with prior payment arrangements with other agencies will be required to abide by the other agency program rules in addition to Butterfly Moments Inc. 8. I understand my participation with housing in the addiction recovery program of Butterfly Moments is contingent upon maintaining compliance with house rules. I understand I am not in a lease therefore breaking rules leading to termination of program activities requires me to immediately leave the property. 9. I agree to allow photographs of me in BFM activities to be used on social media to promote the services provided and share of my recovery journey.
Signed

Clear
Date

Month Day Year
Date
Butterfly Moments Inc Women's Recovery Center

Curfew is imposed prior to employment and then considered on written case by case basis.

Participants will attend 12 meetings weekly while in program (90 meetings in 90 days is suggested

House meetings, AA, NA, and I.O.P. will count toward this goal. Meeting sheets must be signed and verified.

Within 30 days a participants must have an approved sponsor and start step work within 30 days.

Cell phones are NOT allowed. Phone use is for business and scheduled family contact.

No overnight passes or stays will be granted until after 30 days and case by case basis.

If not employed by 30 days, participant must complete and submit at least 3 applications daily. *Application verification is to be reviewed with house director. *If disabled volunteer 20 hours per week.

Participant is to call/talk with the Director or specified person every day for the first month.

All participants will be subject to alcohol and drug test on move in date and anytime thereafter.

All participants will be assigned cleaning and maintenance responsibilities inspected by a senior member. All other house rules will be abided by. Not knowing a rule does not dismiss responsibility to follow rules.

All participants must sign in and out. Listing all destinations on sign out sheet.
Signed

Clear
Date

Month Day Year
Date
Butterfly Moments Inc Women's Recovery Center (931)802-9133 www.butterflymomentsinc@hotmail.com
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THIS IS NOT A LETTER OF ACCEPTANCE

BUTTERFLY MOMENTS INC WOMENS RECOVERY CENTER