Application for Jeffrey’s House

Application Form

Please fill in the form below.
Jeffrey’s House is a sober working environment that provides stabilization and a supportive sober atmosphere.

The general criteria for acceptance into Jeffrey’s House are:
- Residents must be sober and actively maintaining sobriety by being involved in a recovery program.
- Residents must have the ability to pay $175.00 dollars rent weekly. First week and the last 2 weeks’ rent is required, therefore there is a total payment of $525.00 dollars to enter the house. IF A RESIDENT IS ASKED TO LEAVE BECAUSE OF A RULES VIOLATION, THERE ARE NO REFUNDS. If leaving is voluntary, you must give a two-week notice. During this two-week period, payment of rent is not required since all residents have a two-week reserve that will be used to pay their rent.
- Residents must have a willingness to cooperate with other residents and contribute to improving the house and community.
House Rules
- Residents are expected to abstain from alcohol and other substances. If a resident is using alcohol/drugs or involved in any drug activity, they will be immediately discharged. In addition, residents must agree to submit to one (1) randomly scheduled drug test per week.
- Sexual contact between residents is cause for immediate discharge.
- Rent is due by Friday prior to leaving the House for the weekend. Non-payment of rent is subject to disciplinary action and may result in discharge.
- Disruptive, threatening or abusive behavior to residents and/or staff will not be tolerated and subject to discharge.
- Residents must agree to participate in a minimum of one (1) NA or AA meetings per week.
- Residents must agree to participate in one (1) urine screens per week.
- Residents must attend one (1) in-house meeting weekly.
  All residents must be in the house by 11 pm. Sunday through Thursday; weekends by 12 Midnight.
- New residents of Jeffrey’s House will not be permitted to have overnights for one month. New residents have a 9:00 pm curfew for the first 30 days.
- Residents must be willing to do assigned chores.
MY SIGNATURE INDICATES THAT I HAVE READ AND UNDERSTAND ALL OF THE AFOREMENTIONED, AND IF I AM ACCEPTED, I AGREE TO ABIDE BY ALL OF THE RULES AND RESPONSIBILITIES OF THE HOUSE OR BE SUBJECT TO DISCIPLINARY ACTION WHICH COULD RESULT IN IMMEDIATE DISCHARGE.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type or Print (clearly) All Information. Use additional sheet if necessary. Please read application CAREFULLY.

I hereby apply for residency at Jeffrey’s House, and I am providing the following information for use by Jeffrey’s House in determining my eligibility and appropriateness for residency.

Answer all questions that apply.
Full Name

PrefixFirst NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone Numbers
Home:

Area CodePhone Number
Work:

Area CodePhone Number
Cellular:

Area CodePhone Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
E-mail
Are you currently homeless/without a permanent place to live?
Marital Status
Health Insurance
Please include the name of your insurance carrier, account number and expiration date of coverage.
Therapist
Psychiatrist
Physician
Medical Conditon
Are you taking prescription medications?
If yes, please list them
Are you taking Benzodiazepines?
Drug of choice
Have you been to rehab?
If Yes, where?
Are you a recovering
Your sobriety/recovery date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you attend AA or N/A meetings?
Employer
Do you have any outstanding warrants?
Have you ever been convicted of a sex crime?
Have you ever been convicted of arson?
Referral source: (If coming from an institution, which one?)
Release/Discharge Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(Referral source must be filled in, whether an institution or NOT.)
List name of parole or probation officer
List names and telephone numbers of two individuals who may be contacted in the event of an emergency:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Jeffrey’s House is a sober environment and will not tolerate residents using alcohol/drugs. If a resident is found to be using either substance they will be immediately discharged
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent Form
I, as an applicant for Jeffrey’s House, do hereby voluntarily consent to requests for urines and/or saliva specimen and agree to fully participate in the testing program.

If my specimen is found to be positive, I understand I will be immediately discharged from Jeffrey’s House.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have read the aforementioned consent information, rules, criteria and application provided by Jeffrey’s House and I understand that if I am accepted I agree to the following terms:

In addition, I understand there will not be any money refunded if I am required to leave. If leaving is voluntary, I must give a two-week notice.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application Form