SAFE HOUSE RULES
Client Full Name:
*
Client's Email:
*
example@example.com
Client's Phone Number:
*
Please enter a valid phone number.
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CONFIDENTIALITY: There is a strict confidentiality policy. This means that you CAN NOT tell anyone about your safe house location. This includes not disclosing the location and other sensitive information to ANYONE over the telephone, through text, e-mail, etc.
Please provide initials to accept.
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BREAKING CONFIDENTIALITY: If you break confidentiality (i.e., disclose your location) you will be asked to leave immediately. At that time, you will have to take ALL your belongings. Any belongings left on the premises will be discarded immediately.
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RESTRICTED AREA: Only the client and/or approved children are allowed in the safe house. No exceptions.
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NON-VIOLENCE, NON-DISCRIMINATIONPOLICY: Physical, threatening, harassing, intimidating discriminatory and/or similar language, behaviors, or practices are not permitted under any circumstances. This includes both our staff and the staff at a safe location. If you violate this policy, you will be asked to leave immediately. At that time, you will have to take ALL your belongings. Any belongings left on the premises will be discarded immediately.
Please provide initials to accept.
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NO WEAPONS POLICY: No weapons/toy weapons of any kind (i.e., knives, guns, box cutters, tazers, etc.) are allowed in the safe house.
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DRUG/ALCOHOL FREE ENVIRONMENT: This is a drug-free/alcohol-free environment. Violation of this ordinance may affect your participation in this program.
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LOTIERING: Residents shall notloiter or hang out in front of the safe house. Smoking and/or ANY otheractivities, must only be conducted in the reserved area only.
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MINORS: Resident children are ALWAYS to be monitored while in at safe house. No child should be left in the room by themselves.
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DAMAGES: Any property damage that occurs to the propertymust be reimbursed within three days of said event. Residents can payout-of-pocket or subtracted from their program stipend.
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_________I understand and agree to the terms and conditions of this agreement. I understand that failure to comply with the rules and requirements aligned in this agreement, may result in the immediate dismissal from the program.
Please provide initials to accept.
Date
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
*
Clear
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Completed by:
*
Your Email:
*
example@example.com
Your Intake appointment will be:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Take photo of the clients identification.
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