SBH GENERAL RESIDENTIAL INTAKE

Name*

Preferred name and/or pronoun*

Date of Intake*

Date

Date of Birth*

Date

Phone Number*

Email Address*

example@example.com

Facility*

Insurance

Prior Resident?*

YesNo

Gender*

MaleTransgender/MaleFemaleTransgender/Female

Race*

Ethnnicity*

HispanicNot Hispanic

Emergency Contact*

Emergency Contact Phone Number*

Relationship*

Does resident have any food allergies or sensitivities or on any special diets Please list*

Primary Care Physician Name*

Primary Care Physician Phone #*

Case Manager Name*

Case Manager Phone #*

Criminal Justice Involvement in the past six months?*

YesNo

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

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

Last date resident used any drugs or alcohol*

Date

Is Resident Employed*

Yes, Full TimeYes, Part TimeNoNot medically cleared to work

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-RESPOPNSIBILITY

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*

FOOD STORAGE

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

Initial*

RELEASE OF LIABILITY

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 arelease 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: All complaints and disposition that are filed.
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*

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*

Should I be unable to retrieve my personal property, I authorize blanks* to do so.

Signature*

Typed Name*

EXPECTATIONS

As a participant in the Life Changes Program, you are expected to:

Engage in services with Life Changes.
Address goals as established in the Care Plan (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 your referring agency, weekly case management meetings, Tuesday night Life Skills group (required), or recovery focused meetings.

Initial*

RULES OF RESIDENCY AT LIFE CHANGES

1.All residents of Safe Beds shall remain alcohol and drug free at all times. This includes selling, possession, or consumption. 2. All residents of Safe Beds must engage in services with Summit Behavioral Health.

3.Residents of Safe Beds may not at any time exhibit violence or threaten violence, coerce or intimidate members of the household, visitors, volunteers or staff.

4. Racial, LGBTQ-phobic comments, sexual slurs and sexual harassment will not be tolerated.

5. Residents of Safe Beds 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.

6.Residents of Safe Beds must maintain any and all space s/he occupies at the residence in a healthy, clean, orderly, and safe condition.

7. Pets are not allowed without prior written approval.

8. All residents of Safe Beds are required to report any damage or theft to management. No property of the company shall be removed from the premises.

9. Residents of Safe Beds are not authorized to make any changes to any function of the facility, including, but not limited to electrical, plumbing, fire alarm systems (inlkuding smoke detectors) or internet.

10. Life Changes, Inc. 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.

11. Residents of Safe Beds agree to comply with all health and safety protocols as implemented by Life Changes, Inc.

12. Residents of Safe Beds are required to comply with instruction and services provided by Life Changes, Inc. and Summit Behavioral Health Services.

13. Upon discharge, Residents of Safe Beds agree to leave the premises without incident.

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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.

Further, Life Changes, Inc. operates Sober Living Homes and does not provide any medical, clinical or treatment services. Individuals requiring licensed clinical services are referred to an outside entity.

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.

Please note, possession of a Medical Marijuana Card does not give you permission to engage in marijuana use at Life Changes. The program has a zero tolerance for drug use of any type.

By signing, I accept residency in the Life Changes Safe House and agree to comply with all rules as outlined in this document.

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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 concen you, don't mess with it.Treat other how you want to be treated

Initial*

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

Resident Name*

Resident Signature*

Date*

Date

Witness Name (House Manager)*

Witness Signature (House Manager)*

Date*

Date

Photo(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

Take Photo*