Intake Acknowledgment & Consent Form

SECTION 11 — HOUSE RULE ACKNOWLEDGMENT & LIABILITY DISCLOSURE

I understand and agree that:
• Restoration Living is a private sober living residence and not a licensed medical or treatment facility under Illinois law.
• Restoration Living provides housing only and does not provide medical, psychiatric, detoxification, therapy, or clinical services.
• I am voluntarily applying for residence and accept responsibility for my personal recovery and conduct.
• Random drug and alcohol screening may be conducted.
• Violation of house rules, dishonesty, violence, possession of contraband, or substance use may result in immediate discharge in accordance with house policy.
• Restoration Living is not responsible for loss, theft, or damage of personal property.
• In the event of a medical or psychiatric emergency, emergency services may be contacted at management discretion.

SECTION 12 — HIPAA AUTHORIZATION & CONFIDENTIALITY RELEASE

In accordance with HIPAA (45 CFR §164.508), 42 CFR Part 2, and applicable Illinois privacy laws:
• I authorize Restoration Living to obtain and exchange protected health information (PHI), substance use treatment records, and related documentation with treatment providers, courts, probation officers, physicians, detox facilities, case managers, and insurance providers for purposes of eligibility verification, care coordination, safety, and compliance.

I understand that:
• This authorization includes substance use disorder records protected under federal law.
• I may revoke this authorization in writing at any time.
• Information disclosed may no longer be protected once redisclosed.
• This authorization remains valid during residency unless revoked in writing.

SECTION 13 — INDEMNIFICATION, ASSUMPTION OF RISK & CERTIFICATION

I understand that communal sober living environments involve inherent risks including relapse exposure, interpersonal conflict, illness, and emergencies.
To the fullest extent permitted under Illinois law, I agree to:
• Release and hold harmless Restoration Living, its owners, managers, employees, and affiliates from liability arising from my residency, except in cases of gross negligence or willful misconduct.
• Indemnify and defend Restoration Living against claims resulting from my actions, violations of law, or breach of house rules.
• Accept full responsibility for my conduct while residing in the home.
• Certify that all information provided in this application is true, accurate, and complete.

I understand that providing false or misleading information may result in denial of admission or immediate discharge.