Name *
Spouse Name *
Spouse Name
Date of Birth *
Date of Birth
List: Type of ID, State, Number
Homeless *
Home Phone
Home Phone
Sex *
Work Phone
Work Phone
Cell Phone
Cell Phone
Marital Status
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
Emergency Contact Address
Emergency Contact Address
Do you have health insurance?
Provider Name: Provider Phone #: Policy #: Group #:
Do you have dental insurance?
Provider Name: Provider Phone #: Policy #: Group #:
Do you have a car?
If yes, who will take care of it while you are in the program?
If yes, who will take care of it while you are in the program?
Are you currently receiving any type of income?
Have you ever been in the military?

Signing Out and In

For the full duration of your residency you are required to sign-out when leaving the premises, and sign-in upon return.  You must be specific about where you are going when signing out.   If you are going to be later than 30 minutes from your estimated time of return (ETR) you must call the house and notify the house members.

House Curfews

For the first 7 days You Must be accompanied by a House member when leaving the premises unless approved by the House manager. For the first 30 days you are to be in the house by 10 PM, each night of the week. After 30 days you may be granted an extended curfew to 12AM on Weekends. This is at the discretion of the house manager and based on your being employed, rent being current, no fines, overall progress and conduct in good standing. You must seek curfew extension approval by 7 PM the night it is desired.

Overnight Passes

You must complete 30 days of residency, be employed full time, have rent current, no fines and overall progress and conduct in good standing before a request for an overnight pass will be considered. All overnight passes must be requested and approved by the Director 72 hours in advance of the pass. Information as to where you are going and who you will be with is required. Third party verification of your overnight destination may be required prior to, or after its approval. Inconsistencies (dishonesty) will result in pass being denied; pass privilege revoked for 30 days, or termination of residency. You will be allowed 1 overnight per 7 Day period or 2 consecutive overnights within a 14 day period. All Overnights Will Require A Clean U/A Upon Immediate Return To The House.


You are required to be employed full time, (35-40 hours per week). Residents who are unemployed and not receiving monthly disability benefits are required to be off the property from 9 AM – 4 PM, to seek employment. Day labor agencies and inconsistent jobs of less than 35 hours are not accepted as “employed”.


There are certain types of employment that are not allowed, so you should immediately speak with the house manager regarding employment opportunities that might bring your commitment to recovery into question. (cab driving, working in bars, clubs, or places that sell alcohol.)

Designated Smoking Areas

  • Smoking is not allowed in any part of the house.


  • All smoking is to be done outside in the back yard of the house and all cigarette butts are to be discarded in the butt cans placed at the back of the house.

  • Should you be caught smoking in the house or in front of the house, for the first offense you will incur a $25.00 fine, for a second offense you will be discharged from the house immediately.


You will be assigned daily and weekend chores on the Chore Board. (these are mandatory as part of your stay). A $10.00 fine will be issued to any resident that does not perform and maintain their chore duty throughout the course of the day when on the premises, and is not done when the house is inspected by the house manager at 10pm each night.


  • There are absolutely no visitors allowed on premises without prior approval from the house manager.

  • All visitors are to leave the property by 10pm, every night of the week, no exceptions.

  • Non-family opposite sex visitors are not allowed in the home.

  • Family members & Visitors are only allowed to visit on the First Floor area of the home.



Loans/ Borrowing

There is to be no sharing of clothes, personal property, loaning money, borrowing vehicles, including bikes by house residents. You are not to provide another resident with any more than you are willing to lose. This is a risk you take when you place your property in their care.

Drug Urinalysis/ Breathylizer Test

  • You may be requested to submit to a U/A (drug/alcohol test) at any time, which may be required with or without cause.

  • Any argument or refusal to submit to either alcohol or drug testing will result in immediate discharge from the house. Also, another resident may request someone to be tested if a person’s behavior warrants it. Random Group drug and alcohol testing is done at no cost to the resident.Targeted Individual testing resulting from your behavior, attitude, suspicion of other house members etc, will result in a $10.00 charge regardless of the results of the test. In short, you get to pay for the behavior, attitude, or suspicion your conduct has brought about.

  • All positive test results will result in termination of residency for a specified period of time.

  • Any resident who is aware of a major rule infraction, including but not limited to the consumption or possession of alcohol or drugs by another resident and does not notify the house manager immediately will be subject to discharge.