1A. VA INTAKE

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Date of Intake*

Date

Date of Birth*

Date

Facility/Program *

Example: 541/homeless or Pinewood/respite

Payment Source*

VA HomelessVA Respite

Gender *

Example: Male, Female, Transgender

Preferred Name & Pronoun*

Example: Joe, (him, his)

Prior Resident?*

Race/Ethnicity*

Last 4 digits of SS#*

Emergency Contact*

Emergency Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Relationship*

Does resident have any food allergies/sensitivities or on any special diet? Please list*

Primary Care Physician Name*

Primary Care Physical Phone #*

Please enter a valid phone number.

VA Case Manager Name*

VA Case Manager Phone #*

Please enter a valid phone number.

Criminal Justice Involvement?*

YesNo

Supervising Officers Name*

Supervising Officers Phone #*

Please enter a valid phone number.

Mental Health Diagnosis? This information is protected by HIPAA *

If none, enter N/A

Medical Diagnosis? This information is protected by HIPAA *

If none, enter N/A

Is resident on or taking any required Medications? If so, list them. Please spell each medication out no abbreviations*

If none, enter N/A

Is resident allergic to any medications? If so, please list them. Please spell each medication out no abbreviations*

If none, enter N/A

Does resident need a refill on medication?*

YesNo

What medication, including dosage, need immediate refills, be specific*

Enter N/A, if none

Does resident have immediate medical condition that requires immediate attention? If so, be specfic, call 911 and contact your supervisor*

Enter N/A, if none

Does resident have immediate mental health condition that requires immediate attention? If so, be specific, call 911 and contact your supervisor*

Enter N/A, if none

What work documents does resident have in his/her possession. Choose all that apply.*

Photo of Document

YOUR RIGHTS AS A RESIDENT

You will not be abused, neglected, or exploited by any other resident or any other person(s) visiting the facility.
You are not prohibited from speaking to any person who advocates for your rights.
You are treated with dignity and respect.
The facility environment will be a safe and comfortable haven for you.
You are not prohibited from interacting socially with other residents.
You have the right to make your own decisions consistent with facility rules.
You are allowed to vote.

Initial*

NOTICE OF NON-RESPONSIBILITY

Life Changes, Inc. operates a sober living facility in a shared housing model and does not have a safe for safekeeping, or other facilities for safekeeping or storage of personal items, articles of value, or cash. I understand that all my personal items or cash I bring into the shared housing model is entirely at my own risk. Life Changes, Inc. is not responsible for loss, damage, or thefts.

Initial*

RETRIEVAL OF PERSONAL PROPERTY

As a resident of Life Changes, Inc., all property you choose to bring into the residence is your sole responsibility. Life Changes, Inc. does not have a method of safeguarding your property other than normal home safety practices. Please do not bring items that are of value onto the premises. You are limited in space and are not authorized to bring a large amount of belongings into the program. Upon discharge from Life Changes, Inc. you are requested to remove your personal property within five days. If you are unable to remove your property in a timely manner, we are required by law to hold your property for a maximum of thirty (30) days. Your property will be stored in the general storage area at the facility. We are not responsible or liable, directly, or indirectly, in any way for any loss or damage of any kind incurred as a result of, or in connection with, your failure to remove your property. Should you require another person to remove your property, you must authorize that individual in writing and the document must be witnessed. When your authorized individual arrives, they will be required to show their identification.

Initial*

FOOD STORAGE

Life Changes, Inc. provides standard refrigerators and freezers for food storage, but Life Changes, Inc. is not responsible for loss of food by any means, by theft, mechanical breakdown, missing food, weather, acts of God or otherwise.

Initial*

RELEASE

I release Life Changes, Inc. and their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, processors, successors, and assigns, from any and all liability of any kind whatsoever, claims or causes of action. I further agree to pay Life Changes, Inc. any related costs if litigation arises. I am aware that this is a release of liability and a contract. By affixing my initials, I certify that I have read, understand, and agree to this contract and that this contract cannot be modified orally.

Initial*

RESIDENT GRIEVANCE POLICY

It is the policy of Life Changes, Inc. to treat each client with due respect, courtesy and with dignity. However, if a client has concerns about the services they are receiving, they have the right to voice their concerns through the grievance process and shall not be subject to retribution or any other adverse consequences for doing so.

The client is to speak to the Resident Manager and explain the problem. If a solution acceptable to the client is not found, the client is to submit a signed written grievance to the CEO at LifeChangesInc@yahoo.com with the words "client grievance" in the subject line. The grievance will be presented at the next regularly scheduled staff meeting. The response to the client will be presented in writing within 5 working days of the meeting.
If the response does not resolve the matter to the client’s satisfaction, client may have a personal interview with the CEO within 3 days of requesting the interview.
If the interview does not resolve the grievance to the client’s satisfaction, the client may have an interview with the Board of Directors for consideration at their next regularly scheduled meeting. The client may attend the meeting of the Board of Directors and discuss the grievance with the board.
The board may discuss the merits of the grievance in executive session and shall act on the grievance in the form of a board resolution, which shall be communicated to the client. The decision of the board is final.
Should the client have further concerns, the client may address their concerns to the organizations licensing entity: Nevada Department of Health and Human Services Division of Public and Behavioral Health | Bureau of Health Care Quality and Compliance, 72 Fairview Dr. Suite E, Carson, City, NV 89701
Life Changes, Inc. shall maintain a log that lists:
1. All complaints with the facility that are filed.
2. The actions taken by the facility to investigate and resolve the complaint; and if no action was taken, an explanation as to why no action was taken.

Initial*

MARKETING

For the purpose of marketing and to promote the goals of Life Changes, Inc. which is to assist individuals in recovery from an addictive and/or mental health disorder as well as to reintegrate into society, I agree/disagree to allow the organization to use photos of me or written statement from me. This is a non-compulsory agreement and will not affect your stay at Life Changes, Inc.

I agreeI do not agree

RETRIEVAL OF PERSONAL PROPERTY

As a resident of Life Changes, Inc., all property you choose to bring into the residence is your sole responsibility. Life Changes, Inc. does not have a method of safeguarding your property other than normal home safety practices. Please do not bring items that are of value onto the premises. You are limited in space and are not authorized to bring a large amount of belongings into the program. Upon discharge from Life Changes, Inc. you are requested to remove your personal property within five days. If you are unable to remove your property in a timely manner, we are required by law to hold your property for a maximum of thirty (30) days. Your property will be stored in the general storage area at the facility. We are not responsible or liable, directly, or indirectly, in any way for any loss or damage of any kind incurred as a result of, or in connection with, your failure to remove your property. Should you require another person to remove your property, you must authorize that individual in writing and the document must be witnessed. When your authorized individual arrives, they will be required to show their identification.

Initial*

I First Name Last Name hereby authorize First Name Last Name to retrieve my personal property held by Life Changes, Inc. I agree that Life Changes, Inc. is not liable for any property I have left upon my departure.

Signature*

FIRST 30-DAY ORIENTATION & ASSESSMENT PERIOD

During your first 30 days in the Life Changes, Inc. Legion of Brothers Veterans Program, you are expected to adhere to a strict set of guidelines. The initial orientation and assessment period will be as long or as short as is needed to ensure your stabilization. Please keep in mind, the expectations of your orientation period are unique to your situation and the period may be extended or reinstated dependent on your observed needs and compliance with program expectations. Your compliance with program expectations and engagement in Life Changes programming as well as with the Veterans Administration will be staffed weekly to ensure you are receiving and engaging is services to move you to independent living. Your continued stay in the Legion of Brothers Veterans Program will be based on your willingness to engage in services, your level of motivation and your proven determination to create a new way of life. The primary goal of the Legion of Brothers Veterans Program is to move you to independent living within 90-days. You will be provided with every opportunity to achieve this goal.

Life Changes, Inc. operates with a Person-Centered system of care. What this means is that each resident has restrictions, expectations and guidelines that are unique to his or her personal needs. However, every resident of Life Changes, Inc. is expected to follow the same set of rules as laid out in this document or communicated to you.

Initials*

EXPECTATIONS

As a participant in the Life Changes Legion of Brothers Veterans Program, you are expected to:

Engage in services with the Veterans Administration
Address goals as established in the Care Plan (VA goals, program goals, personal goals)
Immediately begin addressing barriers to independent living
Maintain a crime free lifestyle.
Obtain employment or educational/vocational opportunities in the community.
Access behavioral and physical health services as required.
Adhere to all Life Changes program rules.
Your hours to conduct your business are from 8 am to 5 pm. If you have an appointment outside of these hours, you must obtain prior permission from your house manager.

You are required to attend a minimum of 3 self-help groups weekly which may include spiritual services, meetings with the VA, weekly case management meetings, Tuesday night Life Skills group (required), or recovery focused meetings.

Initials*

RULES OF RESIDENCY AT LIFE CHANGES

All residents shall remain alcohol, drug, and gambling free at all times. This includes selling, possession, or consumption. Alcohol/drug use, and gambling, on or off site, is a violation of program rules and will result in consequences up to, and including, termination of program services.
No weapons of any type are allowed on Life Changes property at any time. Failure to comply with this rule will result in immediate discharge.
Approved physical/mental health medication drugs are allowed but must be included in the resident prescribed medication information sheet. Prescribed medication must follow the Company’s Medication Management policy. There is no exception. Prescribed medication must be locked up and dispersed as needed or as prescribed.
Residents will sign and maintain consent for company staff to speak with resident’s Veteran Administration Care Team, criminal justice professionals, treatment team, or other collateral sources that make up their treatment team.
Residents may not at any time exhibit violence or threaten violence, coerce, or intimidate members of the household, visitors, volunteers, or staff.
Racial, LGBTQ-phobic comments, sexual slurs and sexual harassment will not be tolerated.
Residents must sign in and out upon entering and leaving the house.
Residents must attend a minimum of three self-help groups weekly, one of which will be a spiritual service of the residents choosing. Attendance is mandatory.
No visitors are allowed on the premises without the full consent of the house management.
Visitors can visit between 10am and 9pm. Residents may not accept visitors who are under the influence of alcohol/drugs. Visitors are not allowed in the bedrooms and may only visit in the community areas of the house and premises.
Residents must maintain any and all space s/he occupies at the residence in a healthy, clean, orderly, and safe condition.
Residents will respect the privacy and confidentiality of all house residents and will not disclose to anyone outside the household the names or any other information about who resides in any sober living environment owned by the Company.
No fraternization, dating, intimate and/or sexual contact or relationships are allowed between residents or residents and staff.
Pets or animals are ONLY allowed based on company approval and a pet addendum must be signed along with a pet deposit.
All residents’ vehicles must be insured and registered and a copy of both, as well as the residents’ current valid driver’s license, must be given to management. Vehicles that are inoperable are not allowed on company property.
Residents will be immediately terminated for vandalism to company property and will not be allowed to reentry the program until/unless financial restitution is made.
All residents are required to report any damage or theft to management. No property of the company shall be removed from the premises.
Residents are not allowed to conduct ANY repairs to the property or on vehicles inside or outside the residences without written permission.
The company is not responsible for lost, damaged or stolen property. If a resident leaves without taking his/her personal belongings and makes no arrangements with management to retrieve these belongings within 30 days, they will be stored for up to 30 days and donated thereafter.
Resident agrees to comply with all health and safety protocols as implemented by the company.
If, during the course of their stay, new company rules are implemented, the resident agrees to abide by all other rules as implemented.
Food is not to be eaten or stored in any area of the premises other than the kitchen, pantry, or dining area.

Initials*

Facility Expenses

The company oversees all utility use, furnishings, and maintenance of all shared housing space. Each resident shall provide all items required to maintain his/her sobriety and personal care needs. Those living in the sober living facility will be held responsible and accountable for their living environment. In other words, keep the premises in clean condition – bed made, clothes stored in dresser and/or closet, dishes clean and put away, furniture placed where it belongs, cigarettes placed only in the ashtray in approved outdoor locations, floors are swept and/or vacuumed regularly, counters are cleaned, bedrooms and bathrooms are picked up, laundry room is straightened up after each use, as well as the community areas and outside of the premises. To maintain consistency staff will conduct random inspections and provide feedback.

Those living at the sober living facilities are expected to add to a positive experience for others residing at the houses as well as to those visiting. Those that are disruptive to others healing and growth experience may be asked to leave. We expect high standards of conduct from all those residing at the sober living facility. The company encourages and supports an environment of willingness to accept feedback and suggestions from other members of the community and staff.

Initials*

ALCOHOL & DRUG FREE SHARED HOUSING AGREEMENT

Life Changes, Inc. (the Company) has developed a set of rules and guidelines for the structure, safety, growth, and healing of all who reside at the company housing. We will help each individual with their customized approach to recovery and achieving their specific goals. We believe that a large part of recovery and independent living is learning to be personally responsible and accountable for ourselves (thoughts, feelings, and behaviors). The rules and expectations are part of taking personal responsibility and becoming more accountable. The undersigned alcohol and drug-free individual acknowledges and understands that s/he is living in an alcohol and other drug free shared housing environment; residents are living together as a family of persons with various challenges. The undersigned shall be one member of the resident community. The undersigned understands that s/he resides in a congregate housing situation and not in an exclusive unit or space. The undersigned understands that s/he does not reside as a tenant with exclusivity rights or possession rights in any housing space, exclusively. The undersigned agrees to vacate the shared housing accommodations if the company, in its sole discretion, determines the undersigned has used alcohol or illicit drugs, regardless of the location of use, or has otherwise violated any of the House Rules including, but not limited to, continued violation of house rules, bullying, intimidation, violence or threat of violence. The undersigned agrees to adhere to each of the sets of Rules outlined in this document. The undersigned agrees that adherence to each of the following Rules, Regulations and Guidelines is, at a minimum, a condition precedent for continued residency.

I agree to the Alcohol & Drug Free Shared Housing Agreement

Initials*

MEETINGS & PERSONAL GROWTH

I understand that Life Changes, Inc. operates sober living homes and as a resident, I agree to address my personal growth and recovery concerns, my spiritual growth, and my employment and/or educational pursuits and any barriers I may have to independent living. I further understand that I am required to attend personal growth, therapy, or other services as detailed in my care plan. I also understand I am to attend a spiritual event of my choosing on a weekly basis. I am clear that this is a requirement of my stay at Life Changes. Should I choose not to follow this requirement, I understand I am making the choice to be discharged from the Life Changes program.

I agree to the Meetings & Personal Growth Requirement

Initials*

IMMEDIATE DISCHARGE PROTOCOL & RANDOM URINALYSIS/BREATHALYZER TESTING

It is the policy of Life Changes, Inc., hereinafter referred to as the “Company,” to provide each client with an alcohol- and illicit drug-free environment. Urine drug screens and breathalyzer tests will help us in achieving this goal. As a client of the company, I understand I will be expected to submit a urine sample for drug and/or alcohol screening under the supervision of staff. I understand I may be requested to provide a urine sample upon admission, randomly up to three times per week and/or upon suspicion of drug or alcohol use. My initial indicates I have acknowledged the company’s protocols, and I hereby consent to the administration of urine drug screening and/or breathalyzer tests by the staff of the company. I understand that my refusal to provide a urine specimen upon request could result in my being asked to leave housing and to forfeit all my rights and privileges as a client. Drug/breathalyzer testing is mandatory and will be performed randomly. All residents agree to take thrice weekly and/or on demand random drug/breathalyzer tests. Any refusal or attempts to bypass, deceive, or fail to provide a urinalysis sample for testing or a positive test indicating you have used substances/alcohol is grounds for immediate expulsion from the sober living program. If a resident is under the influence of alcohol or drugs, creates a disruptive or unsafe environment, the resident will be discharged and asked to leave the premises immediately. The resident agrees to vacate any facilities owned or operated by Life Changes, Inc. without incident. The resident understands that should s/he cause a disruption the police department may be called to remove the resident thereby ensuring the therapeutic milieu of the facility.

Initials*

PERSONAL HYGIENE & HOUSE CLEANLINESS

Residents are required to shower regularly, wash their clothes, and keep their personal living areas neat. This means picking up your clothes, making your bed, emptying your trash, and keeping your personal area clean. At NO TIME are you allowed to have food or open food containers in your room.

In general:

If you sleep on it, make it
If you wear it hang it up
If you drop it pick it up
If you eat out of it wash it
If you step on it pick it up
If you open it close it
If you empty it, fill it up
If it rings answer it
If you turn it on turn it off
If you make a mess clean it up
If it belongs to someone else don't touch it
If you move it put it back
If you don't know how to operate it don't touch it
If it doesn't concern you, don't mess with it.
Treat others how you want to be treated.

Initials*

WAIVER OF LIABILITY & HOLD HARMLESS AGREEMENT

In consideration of receiving housing and transportation services from Life Changes, Inc, hereinafter referred to as “Company”, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE, Company, and any of their officers, agents, servants, volunteers, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, disputes and causes of action whatsoever arising out of or related to any loss, damage, or injury, including without limitation, death, bodily harm and/or injury that may be sustained by me and/or other family members that are utilizing the transportation service, and/or damage to any property belonging to me and/or other family members that are utilizing transportation service, as the case maybe, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise by any reason whatsoever, while utilizing such services, or while in, or upon the premises where such services may be provided. I am fully aware of the unusual risks involved and hazards connected with this activity, including but not limited to travel risks and/or road hazards. I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING WITHOUT LIMITATION DEATH, which may be sustained by me, or any loss or damage of property owned by me, as a result of being engaged in such activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES OR OTHERWISE BY ANY REASON WHATSOEVER. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage, or costs, including court costs and attorney fees, that RELEASEES may incur as a result of my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise by any reason whatsoever. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, during the length of my life, and my heirs, assigns and personal representative, should I be deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Operation. IN SIGNING THIS RELEASE, I, ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.

Type Residents Name

Initials*

The protocols, rules and expectations of the Life Changes Legion of Brothers Veterans Program have been clearly explained to me and I agree to adhere to all requirements and accept residency.

When resident leaves Life Changes, he plans to trasition to:

example, motel, return to homelessness, own home, with family, etc.

Resident Typed Name

Signature*

Date*

Date

Witness Typed Name

Signature*

Date*

Date

(A head shot photo of every client is required. If you are unable to take a photo for intake, please contact the administrative assistant for guidance immediately.)*