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  • PRESCREENING

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  • DO NOT COMPLETE THE REST OF THIS FORM IF YOU ANSWERED NO TO THE LAST QUESTION.

  • INTAKE

  • *All prospective residents of Restoration House are required to present a clean drug screen prior to admission. Individuals who do not meet this requirement may be required to complete a detoxification program before acceptance.*

  • *Participant Well-Being and Program Readiness*

    We strive to create a safe and supportive environment for everyone in our program. If you are currently receiving treatment for a mental health condition or have concerns about how participation may affect your well-being, we may ask for additional information or an evaluation from a mental health provider.
    This is not a screening-out process but a collaborative effort to ensure that the program can safely meet your needs and that appropriate supports are in place.

  • *If a participant is taking a medication that cannot be safely stored or administered within the safe house, staff will work with the individual and their healthcare provider to explore alternative arrangements.
    In some cases, this may include discussing possible medication adjustments or identifying another placement that better supports the participant’s needs.*

  • Restoration House Guidelines

    *Our goal is to create a safe, supportive, and healing environment for everyone in our community. To ensure that we can provide the right level of care and maintain safety for all residents, there are some situations where our program may not be the best fit at this time.
    If any of the following apply, we will work together to discuss options and connect you with resources or programs that can best support your needs.


    • Medication and Treatment:
    Some medications — including certain prescriptions used for opioid-use disorder treatment (for example, methadone, buprenorphine, dolophine, or suboxone) — or medications not on our allowed medications list (available upon request) cannot be safely managed within our current setting. If this applies to you, our team will help explore alternative programs or services that support your treatment plan.
    • Medical and Self-Care Needs:
    Our facility is not equipped to provide ongoing medical or personal-care assistance. Individuals who need a higher level of medical or daily-living support may benefit from a program designed to provide that kind of care.
    • Safety and Stability:
    For the well-being of all residents, we may not be able to accept participants who have recent histories of violence, arson, or other behaviors that could pose a safety risk to themselves or others. When possible, we’ll help connect you with resources that can offer more appropriate support until it’s safe to join.
    • Legal Concerns:
    Active arrest warrants or unresolved legal issues can interfere with program participation. We encourage applicants to work with legal counsel to resolve these matters before entry, and we can assist with referrals or documentation if needed.
    • Sex Offender Registry:
    Due to housing and safety regulations, we’re unable to accommodate individuals currently listed on the sex-offender registry. We can provide referral information for alternative housing and treatment programs.
    • Relationships and Recovery Focus:
    Recovery is a time to focus on healing and personal growth. We ask participants to refrain from romantic relationships during their first 12 months in the program, as suggested by NA/AA. If you’re in a relationship that you plan to continue, we can talk together about whether this program will best support your goals right now.*

                      About the Five14 Restorative Care Program

    Five14 is a no-cost, restorative care program designed to provide a safe, stable, and healing environment for survivors as they rebuild their lives.


    Program Overview:

    Our program typically lasts up to one year, with the initial 30 days focused on helping you settle in and assess together whether Five14 is the best fit for your goals and needs. Extensions beyond one year may be considered on an individual basis, depending on progress and available support.


    • Health and Wellness:
    Currently, we are a non-smoking facility. To support your well-being and comfort, nicotine patches or gum are available at no cost for those who wish to use them.
    • Communication and Safety:
    During the first 30 days, we focus on helping residents establish safety, stability, and trust. Upon arrival, residents personal phones will be replaced with a safe phone to contact pre-approved, supportive persons. This helps maintain healthy communication and ensures safety for everyone in the home.
    • Program Structure:
    Five14 offers a structured, restorative environment centered on healing and personal growth. Each day includes purposeful activities, group and individual counseling, and opportunities to build life skills and community.
    • Participation and Commitment:
    Participation in Five14 is voluntary, but residents are asked to commit fully to the program’s structure and rhythm. This is a supportive residential program—not a drop-in or halfway house setting—and the structure is designed to create stability and promote recovery.
    • Therapeutic Healing:
    Residents are encouraged to engage in both group and individual trauma-informed counseling. These sessions are an important part of the healing journey and are tailored to each person’s comfort level and progress.
    • Growth and Responsibility:
    As residents become more comfortable and demonstrate progress, they may take on additional responsibilities and privileges within the home. This process happens gradually and is based on readiness and collaboration with staff.
    • Community Living:
    Residents share living space and responsibilities with other survivors. Community life offers opportunities to practice communication, teamwork, and mutual support. We believe that relationships built on trust and respect are essential parts of healing.

     

    Our Hope:

    Our hope for every survivor who enters Five14 is that you find safety, rest, and renewal here—and that this experience helps you build a strong foundation for the next chapter of your journey.

     

    Welcome To:

     

     

  • Five14 Revolution Client Release of Information and Background Check

  • I * , DOB *, a client of Five14 Revolution authorize Five14 Revolution personnel to release and/or obtain information from/ to the following entity: _________VICTIG / pertaining to my:

  • This authorization will expire in one year from the date signed unless revoked at an earlier date.

  • I may revoke this consent at any time by written notification to Fivel4 Revolution. I understand that the revocation has no effect on actions taken prior to the date of revocation. I approve the exchange of information and understand that confidentiality cannot be assured when information is faxed. My initials below signify acceptance of the risk that confidentiality may be breached when information is faxed. I understand that the information provided can be given either written or verbal. I understand that only the information specified below may be disclosed and that the information is protected by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA Federal regulations prohibit you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or his/her parent or legal guardian unless otherwise permitted by such regulations. Pursuant to Public Law 93-579, the Privacy Act of 1974, I hereby request and authorize the above named agency or organization to release information on my behalf to Fivel4 Revolution. I understand that the information released may be sensitive or confidential in nature. This authorization is valid only if received within 60 days of being signed.

     

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