DAILY LIVING RECOVERY HOUSE APPLICATION

Name*

Date of Birth*

Date

Age

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Most recent address

What is your current source(s) of income?

How much is your monthly income?

Any preexisting medical conditions?

If you are under a physician's care, please list the reason(s), name(s), and contact information

Do you have any physical/emotional/mental limitations?

Are you taking any medications

YesNo

Please list medications and frequency

Do you have an advocate/social worker/case manager/therapist?

YesNo

If so, list the name and contact information.

Are you recovering from substance use disorder?

Yes, AlcoholYes, Drug addictionNo

Sobriety Date

Date

If you have been in treatment for substance use, either inpatient or outpatientwithin the last two years, give the name of each program (i.e. detox, treatment center, halfway house)the dates you attended, and reason for leaving.

Substance of Use (Check all that apply and list specific forms of substance)

Have you been sober/in recovery in the past?

YesNo

When and for how long?

Why did you return to use?

Are you currently in detox, CSS, TSS, or long-term residential program(halfway-house)?

YesNo

If yes, name of the program

How many meetings do you attend per week?

Do you have a sponsor/mentor?

YesNo

If not, why?

What is your recovery pathway (How do you plan to be sober/clean)?

Recovery goals (Be specific)

Recovery plan (Be Specific)

Do you have any open court cases?

YesNo

Court

Are you on Probation/Parole?

YesNo

Probation/Parole officer(s) name and contact information

Are you in Recovery Court?

YesNo

Where?

What other information would be helpful for us to know about you to serve you best?

List names and telephone numbers of two individuals who may be contacted in the event of an emergency:

House Standards

1. Weekly fees are due every Friday.
2. Two drug/alcohol urine analysis tests per week and random testing when requested. Breathalyzed randomly.
3. Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medications, drugs, or misusing prescribed or over-the-counter medications may require immediate dismissal.
4. If a member is taking an over-the-counter drug, vitamin, energy drink, etc., it is the member’s responsibility to ensure that it will not cause false positive results.
5. Any and all prescription and non-prescription medication(s) will require approval from Daily Living Recovery House.
6. Smoking/vaping in designated areas only.
7. A member is to attend a minimum of three meetings (AA/NA, Smart Recovery, etc.) per week. If a member is not working full time, a member is to attend a meeting every day. Multiple meetings in one day will be considered one meeting.
8. Member is to attend all mandatory in-house meetings.
9. The kitchen is to be cleaned, dishes washed, and put away immediately after each use.
10. A member is not allowed in another member’s room.
11. A member is responsible for his guest’s behavior. Guests are only allowed in common areas unless permission is given. Women or significant others are not allowed in the house unless the member has received permission from the staff.
12. Every member is to clean up after himself, make the bed, keep his room clean and neat, and complete chores daily.
13. Failure to maintain good hygiene and/or a clean-living environment may ultimately result in dismissal.
14. No halogen lamps, candles, or incense.
15. Curfew Sunday through Thursday is 11 PM, Friday and Saturday midnight.

Signature*

Date

Equity and Inclusion Pledge

Daily Living Recovery House is committed to creating a brave, safe, and diverse environment and is proud to be a welcoming and inclusive sober living home. All qualified applicants will receive consideration for sober living without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

As a DLRH guest, I pledge to the DLRH Equity and Inclusion pledge and if I violate this pledge, I understand I will engage in restorative justice, commit to learning, or be subject to dismissal from the home.

Financial Agreement

The weekly rent at Daily Living Recovery House is $275, or $1,191 per month, with an initial move-in fee of $550 covering the first week’s rent, onboarding supplies, and administrative costs. Residents may be eligible for a refund of the last week’s rent if there are no major rule violations, property damage, or outstanding balances. A door lock replacement fee is $20. If a member receives income on a monthly or bi-weekly basis, the member agrees to prepay weekly fees up to the date that the member receives their next income payment

Refund Policy

The weekly rent at Daily Living Recovery House is $275, or $1,191 per month, with an initial move-in fee of $550 covering the first week’s rent, onboarding supplies, and administrative costs. Residents may be eligible for a refund of the last week’s rent if there are no major rule violations, property damage, or outstanding balances.

I understand that failure to make consistent scheduled payments when due may result in my dis- charge from Daily Living Recovery House. In acceptance of the FINANCIAL AGREEMENT with Daily Living Recovery House, I agree that to qualify for Daily Living Recovery House I must adhere to the House Agreements and make my scheduled payments when due. I further understand that failure to make payments when due may result in my dismissal from Daily Living Recovery House.

Any unpaid account balance at the time of moving out is subject to the cost of collections and lawyers’ fees if required. Residents will be informed of payments from 3rd party payers for any fees paid on their behalf. Residents must take responsibility for their own and other residents’ safety and
health. Residents must understand that the length of stay at the house is “resident-driven.” All emergency contact information must be collected from residents.

I promise to settle all charges with Daily Living Recovery House. All its charges were rendered to me from admission to the day of moving out. I understand the refund policy and I understand that the total of such charges is due and payable according to this FINANCIAL AGREEMENT.

Resident Signature*

Date

ATTENTION: Daily Living Recovery House may require immediate dismissal from the house without prior notice of any member for the following reasons:

1. Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medication, or drug(s)

2. Misusing prescribed or over-the-counter medication(s)

3. Changing medication(s), dose amount, starting, or stopping medication(s) without prior authorization from Daily Living Recovery House.

4. Allowing a person on the property who presents to be under the influence of drugs or alcohol.

5. In noncompliance with the house standards, policies, or procedures.

6. In noncompliance with drug and alcohol policy.

7. In default of payment of weekly membership fees.

8. Has disruptive, disrespectful, or hostile behavior towards Daily Living Recovery House.

9. Is verbally or physically abusive towards another member of Daily Living Recovery House.

10. Bullying or intimidation of house members or Daily Living Recovery House.

11. Causes damage or destruction of property.

12. Involved in illegal activity.

I have read the above ATTENTION notice and understand that I am applying for membership at, Daily Living Recovery House, as a member of a recovery community. I agree to abide by Daily Living Recovery House's principles and fully subject myself to Daily living Recovery standards, policies, procedures, and direction from Daily Living Recovery House, and comply with the drug/alcohol policy of Daily Living Recovery House I understand that I am subject to immediate dismissal if any of the preceding occur.

If I am on Probation or Parole, I understand that they will be contacted immediately upon my dismissal. By signing below, I am giving my authorization to Daily Living Recovery House to speak with any member of the probation/parole department at any time for any reason.

I allow Daily Living Recovery House to use my picture on social media and websites.

Work/Volunteer Policy

As a member of Daily Living Recovery House, I agree to either work, attend school, attend classes, volunteer, or do any other productive activity approved by Daily Living Recovery House. Volunteering in lieu of work is only an option for someone who is unable to work.

Personal Property Policy

All personal property will be kept neatly in the member's room. Members are not allowed to borrow any property of another member without the other member's consent, this includes food. Daily Living Recovery House is allowed to inspect all personal property, this includes any electronic property. When I leave Daily Living Recovery House agrees to take all my property with me. If I leave for any reason without personal property, it will be held for up to 48 hours. After 48 hours the property will be discarded or donated unless arrangements have been made with Daily Living Recovery House.

Medication Policy

The member is responsible to provide documentation for any medication for approval by Daily Living Recovery House. This includes all prescribed and non-prescribed medications. Medications are not to be in the possession of, shared with, or sold to any house member. Medications are to be taken only as prescribed. Daily Living Recovery House has the right to count medications that are held by house members at any time. Not taking medication as prescribed or misusing medication may require immediate dismissal. If a member is in possession of, using, sharing, buying, or selling alcohol, unauthorized medications, misusing prescribed medications, or any drug the member may be required to leave Daily Living Recovery House property immediately. Some medications are to be held by Daily Living Recovery House.

Changing medication(s), amount, or starting medication(s) without notifying Daily Living Recovery House may require immediate dismissal. It is the member's responsibility to ensure that medications will not cause a false positive. When leaving Daily Living Recovery House, I agree to take all medications with me. Any medication may be disposed of after 48 hours of members exiting Daily Living Recovery House unless arrangements have been made with Daily Living Recovery House.

Signature*

Date

Alcohol/Drug Testing Policy

Members are to comply with scheduled two weekly drug/alcohol analysis testing as well as random tests, including breathalyzing. Compliance with random drug/alcohol analysis tests are to be provided within 45 minutes of request. If an immediately suitable urine sample cannot be produced, a member is to be in the presence of Daily Living Recovery House until a suitable sample is provided. Requests to be breathalyzed will be complied with immediately. If drug/alcohol analysis test is missed, it is considered a positive test and may require immediate dismissal without incident.

Signature*

Vehicle Waiver

I understand that I may request or be offered transportation from time to time from a house member, volunteer, or managing member of Daily Living Recovery House. I hereby indemnify Daily Living Recovery House LLC, house members, volunteers, and/or managing members of Daily Living Recovery House from all damage or injury caused to me or others when I willingly accept transportation to or from any location or event, whether Daily Living Recovery House is related or not.

Signature*

Medications/Dosage

Gender:

MaleFemaleNon-Binary

Race/Ethnicity:

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, other Spanish culture or origin regardless of race.White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe the Middle East, or North Africa.Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of AfricaNative Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India,Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of theoriginal peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the of the above five races.I do not wish to disclose.

DAILY LIVING RECOVERY HOUSE

Self-Identification