CG Charitable Services Sober Living Transitional Housing Program

CG Charitable Services Sober Living Transitional Housing Program
Demographic Information
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Name/Alias/Preferred Name

AliasPreferred Name
Gender assigned at birth
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How were you referred to CG Charitable Services' Sober Living Transitional Housing Program
Enter Name of person, program, center, organization, or health care provider who referred you
Enter N/A if self referral or from flyer
Emergency/Next of Kin Infomation

Individuals identified as primary or secondary next of kin automatically receives release of information. For placement, you must consent to information release about you or your circumstances in the event of relapse or emergency.
Primary Emergency Contact Name / Next of Kin

First NameLast Name
Primary Emergency Contact / Next of Kin Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact Name / Next of Kin

First NameLast Name
Secondary Emergency Contact / Next of Kin Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Highest Educational Attainment
Current Employment Status
Are you currently an active Client with the Texas Workforce Commission (TWC) Vocational Rehabilitation Services?
Are you a Military Veteran?
Legal & Justice Involvement Screening
What is your current justice system involvement
Enter your Probation/Parole Officer Name
Enter N/A if you are not on probation or parole.
Enter your Probation/Parole Officer Phone Number
Enter N/A if you are not on probation or parole

Enter the charge(s) you've been convicted of, date of offense(s), and county in which the

Rows	Charge	Date	County	Disposition
Offense
Offense
Offense
Offense
Offense
Offense
Offense
Offense

Health, Medical & Medication Profile
What is your primary health insurance status (check all that apply)
Do you currently have a health care provider?
Provide a list of prescribed medications you are taking, the prescribing doctor and the pharmacy that fill the prescriptions.
Sobriety & Recovery Status

Before your commitment to recovery, what were your recreational drug(s) of choice?

Rows	Yes	No
Depressants (Alcohol, Benzodiazepines, Barbiturates, GHB)
Dissociatives (Ketamine/PCP/Nitrous Oxide)
Inhalants (Solvents, Aerosols (glue, paints, gasoline), Poppers)
Opioids (Heroin, Oxycodone, Hydrocodone, Morphine, Fentanyl or Codeine)
Psychedelics/Empathogens (LSD/Molly/Ecstasy/DMT)
Stimulants (Cocaine/Crack, Amphetamines, Methamphetamine, Adderall, Ritalin)
THC (Marijuana, Synthetic Marijuana, including edible forms)

Date of last use

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Detox Status: Have you completed medical detox
Are you under current care supervision?
List your provider of care supervision. Separate multiple providers using a comma.

Program Fee & Service Agreement Acknowledgement
Inclusive Services & Fee Allocation

The weekly fee of $250.00 covers full residency participation in the Level II Monitored Recovery Housing Program and is inclusive of the following provisions:

Included Program Coverage:
1. Housing & Occupancy - Furnished bed space and full access to common areas at residence
2. Utilities & Amenities - Electric, water, gas, high-speed Wi-Fi internet, and laundry facility access.
3. Food & Groceries - Full household groceries, staple foods, and shared community meal supplies.
4. Substance Testing - Routine and randomized urine drug screens (UDS) and breathalyzer monitoring.
The weekly fee is to be paid recurringly, every Friday by 5pm CST.

Payment Terms & Schedule
1. First Week Fee: The initial weekly payment of $250.00 is due upon move-in/intake.
2. Payment Methods: Fees must be paid electronically, via cashier's check, or money order payable to CG Charitable Services. Cash is strictly prohibited.
3. Grace Period & Late Fees: A 24-hour grace period is extended. Payments received after Saturday at 5:00 PM CST are subject to a $25.00 late fee unless prior written arrangements have been made with management.
Refund & Discharge Policy
1. Voluntary Move-out: Residents providing a 14-day written notice of voluntary departure are eligible for a prorated refund of any unearned fees paid in advance for future weeks.
2. Involuntary Discharge (Relapse or Rule Violation): In alignment with NARR/TROHN ethical standards, if a resident is discharged due to relapse or safety/rule violations, unused pre-paid weekly fees beyond the current week will be refunded within 14 business days. Fees applied to the current active week are non-refundable.
By signing below, I acknowledge that I have read, understood, and agree to the payment schedule and terms outlined in this Agreement. I confirm that I am entering this recovery residence voluntarily to support my sobriety journey. Signature:
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent for Release of Information & Emergency Protocol

To establish clear medical emergency protocols, safety authorizations, and conditional disclosures of protected health information in compliance with NARR/TROHN Level II standards, 42 CFR Part 2, and HIPAA in the event of an emergency, relapse, or acute behavioral crisis.
Designate Emergency Contacts

I hereby authorize CG Charitable Services staff and representatives to contact the designated individuals listed below in the event of a medical emergency, acute mental health crisis, suspected overdose, or active relapse requiring program discharge or transfer of care. I also, agree that I will provide a primary and secondary emergency contact, sponsor/peer recovery coach.

Medical Emergency & Overdose Response Authorization

I acknowledge and agree to the following emergency interventions in the event of a medical distress or overdose incident:

Emergency Medical Services (EMS / 911): CG Charitable Services staff, House Managers, or resident leaders are authorized to contact emergency services (911) immediately if I am found unconscious, unresponsive, or in severe physical or psychiatric distress.

Naloxone (Narcan) Administration: I understand that CG Charitable Services maintains Naloxone (Narcan) on-site. Staff and trained resident leaders are authorized to administer Naloxone and perform life-saving measures if an opioid overdose is suspected.

Treatment Facility / Hospital Transport: I authorize staff to disclose relevant medical history, known prescription medications, and substance history to responding paramedics, emergency room personnel, or crisis intervention specialists.

Scope of Release & Federal Confidentiality Notice

I understand that my alcohol and/or drug abuse patient records are protected under Federal regulations governing Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA, 45 CFR Pts. 160 & 164). Information disclosed pursuant to this consent will be strictly limited to what is necessary to resolve the emergency, coordinate medical/clinical care, or facilitate safe housing transitions.

Right to Revoke: I understand that I have the right to revoke this consent in writing at any time, except to the extent that CG Charitable Services has already taken action in reliance upon it. Unless revoked earlier, this consent automatically expires one (1) year from the date of execution or upon my formal discharge from the program.
By signing below, I confirm that I have read, understood, and voluntarily agree to the terms of this consent for release of information and emergency protocol acknowledgement.
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Program Rules and Acknowledgement
Core House Rules & Operating Guidelines

Sobriety & Drug-Free Environment

Zero Tolerance: Abstinence from alcohol, illicit drugs, unauthorized prescription medications, and mind-altering substances is strictly required.

Drug & Alcohol Screening: Residents must submit to mandatory, randomized urine drug screens (UDS) and breathalyzer tests weekly or upon request by the House Manager or staff. Refusal or failure to provide a sample within 2 hours is treated as a positive test.

Medication Storage: All prescription and over-the-counter medications must be registered during intake and stored securely in the resident’s assigned lockbox. Sharing or transferring medication is grounds for immediate discharge.

Weekly Fees & Inclusive Amenities

Fee Structure: Program fee is $250.00 per week, due every Friday by 5:00 PM. A 24-hour grace period is available with a $25 fee.

Included Services: The $250/week covers full occupancy, all household utilities (water, power, gas, Wi-Fi), and basic house groceries/food provisions.

Payment Methods: Payments must be made via electronic transfer, cashier’s check, or money order. Cash is strictly prohibited. Receipts are issued for every transaction.

Curfews & Phase System

Phase 1 (Days 1–30): Curfew is 10:00 PM (Sunday–Thursday) and 11:00 PM (Friday–Saturday). Overnight passes are not permitted during Phase 1.

Phase 2 (Days 31+): Earned curfew extends to 11:59 PM (Sun–Thu) and 1:00 AM (Fri–Sat). Overnight passes (up to 48 hours) may be requested 48 hours in advance, subject to House Manager approval and the program participant being in good standing.

Exceptions: Curfew can be flexible upon submission of curfew allowance form. Allowances are only provided to program participants who have a verifiable job schedule that requires an extension of curfew or is participating in a work based learning program requiring an extension of curfew. Residents must be in phase 2 to qualify for an exception.

Mandatory Recovery & Productive Hours

Mutual Aid Meetings: Residents must attend a minimum of 3 mutual-aid recovery meetings per week (e.g., AA, NA, CA, SMART Recovery) and maintain meeting verification sign-off sheets.

Sponsorship/Mentorship: Residents are required to obtain a recovery sponsor or peer mentor within 14 days of move-in.

Productive Activity: Residents not enrolled in full-time treatment or education must engage in at least 30 hours per week of productive activity (employment, active job search, vocational training, or approved community volunteering).

Weekly House Meeting: Attendance at the weekly House Meeting (held every [Day, e.g., Sunday at 6:00 PM]) is mandatory for all residents.

House Community & Chores

Chore Allocation: Every resident is assigned daily/weekly household chores to maintain kitchen cleanliness, common area upkeep, and yard maintenance.

Room Inspections: Bedrooms and common areas must be kept clean and tidy. Daily bed-making and tidy spaces are inspected by the House Manager.

Kitchen & Meals: Household groceries are provided. Residents share cooking responsibilities and are responsible for cleaning all dishes and food prep areas immediately after eating.

Smoking & Vaping: Designated outdoor smoking/vaping areas only. Smoking or vaping inside any room of the residence is strictly prohibited.

Front House Useage: The front of the residences are intended for entering an exiting the residence. Smoking or "hanging out" in the front yard is not permissible.

Resident Grievance Policy

Residents have the right to present grievances without fear of retaliation.

Internal Resolution: Submit a written grievance to the On-Site House Manager or Program Director within 72 hours of an incident. Management will investigate and issue a written response within 5 business days.
By signing below, I acknowledge that I have read, understood, and agree to the payment schedule and terms outlined in this Agreement. I confirm that I am entering this recovery residence voluntarily to support my sobriety journey. Signature:
Date of Signature

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

CG Charitable Services Sober Living Transitional Housing Program

Demographic Information

Emergency/Next of Kin Infomation

Legal & Justice Involvement Screening

Health, Medical & Medication Profile

Sobriety & Recovery Status

Program Fee & Service Agreement Acknowledgement

Consent for Release of Information & Emergency Protocol

Program Rules and Acknowledgement