ConsentforServicesAgreement
I hereby authorize staff and volunteers at Sober Solutions Transitional Housing Program to provide Residential Recovery and Reentry Related Transitional services in accordance with my individual service plan.
Services will include:
- Structured and supportive temporary living
- Safe housing community conducive to chemical dependency recovery and reentry
I understand that if I refuse to follow my plan and the rules set forth in this agreement which states:
- stay clean and sober,
- stay fully engaged in my designed program,
- report my progress to site managers and admin Staff
- cooperate with the random and just cause urine analysis screening
If found to be in violation of any rule in this agreement, I will receive a Corrective Action Memo. I understand that this memo may include a curb and cure clause. I understand that the curb and cure clause may not be an option depending on the nature of my action. I understand that if I refuse to curb and cure and /or comply with the recommendation listed on the Corrective action memo, I will be discharged from this housing program immediately and given 72 hours to remove my property from the premises in accordance to this agreement for failure to comply.
I understand that there is a Zero Tolerance Drug and Alcohol Policy in effect and if I violate this policy for any reason I must vacate my living unit immediately. I understand that I will have 72 hours to remove my property from the premises in accordance to this agreement for failure to comply.
I agree to abide by these rules and acknowledge that Sober Solutions Transitional Housing Program may amend them at any time in order to maintain a safe and productive environment for recovery.
I understand that Sober Solutions Transitional Housing Program is not responsible for any loss, theft or damage to my personal property during my stay.
I acknowledge my personal belongings will be donated to a local non-profit agency within 72 hours promptly after my departure upon termination unless I make arrangements with the Program Director to return my property.
I understand Sober Solutions Transitional Housing is NOT responsible for my personal belongings.
I further understand that Sober Solutions Transitional Housing Program is not responsible for any injury, harm or incapacity resulting from my condition, or any action on my part in conformance with all the rules. I agree to behave in a manner that does not inflict harm on me or to others during my stay. I agree to hold all parties harmless.
I understand during the first 14 days of my stay, I am on blackout status and must adhere to a 9:00 pm curfew. I also understand that my blackout status may be extended to 30 if deemed necessary during my intake.
I understand regular curfew is 10pm (Sunday–Thursday) and 12pm (Friday and Saturday) after my initial blackout period.
I understand I am allowed 2 overnight stays per week.
I understand that if I am Community Custody with Washington State Department of Correction or any other Federal or State Community Custody. I must provide written proof from my Community Custody Officer that I have permission for overnight stay.
I understand if I sign-out for longer than 24 hrs, I will check in daily.
I understand that if I fail to check in for (3) three consecutive days without permission, my housing will be considered abandon and this agreement will terminated.
I acknowledge that I am required to sign out and leave a contact number where I can be reached.
SERVICE FEE’S
I agree to pay a one time $150 non refundable processing fee when moving in.
I understand payments must be made by Money Order. I understand housing payments are due on or before the 5th of the month. I understand a $50.00 late fee will be imposed if housing payment is not received by the 5th of the month.
I understand that I am responsible for my basic hygienic supplies to include toilet paper, paper towels etc..
I understand that it is my responsibility to secure either a voucher or rental assistance on or before the 1st of each month if necessary, and must show proof thereof, on or before the 5th of the month,
Failure to make payment or provide proof of funds for payment will result in a penalty of $50.00, and termination from the program after the 5th of the month.
I acknowledge that the processing fee may be increased any time and that I will be given a 30 day written notice.
I acknowledge that there are no refunds of any fees and housing payments for any reason no exceptions.
I also acknowledge that Sober Solutions Transitional Housing Program may pursue collection of all money’s owed for unpaid services and for any damage done by me to Sober Solutions property.
NO TOLERANCY POLICY:
The following violations will be subject to termination from the program :
Please initial each of the following
1. __ I understand this is a ZERO TOLERANCE ENVOIRNMENT, and this policy is strictly enforced.
Violating this agreement by using any drugs or alcohol and possessing any paraphernalia is strictly prohibited. This includes falsifying illnesses to obtain Prescription Narcotic’s (Drug Seeking Behavior).
2. ___Declining to cooperate with a drug test.
3. ___Possession of any weapons, engaging in any illegal activities and/or
Associating with other persons who are engaged in illegal activities is a
Violating of the policy’s set forth in this agreement.
4. ___Engaging in threats, name calling, harassment, any verbal or physical
Abuse, violence or threats thereof directed at any one involved with Sober Solutions
Transitional Housing Program.
PROGRAM, GENERAL AND VISITOR RULES:
1. ___CLEANLINESS AND SANITATION: I acknowledge that I am required
to bath regularly, and I will wash and change the bedding weekly. I am required to
keep my living and common areas neat and clean at all times. I am also responsible for keeping the stove, fridge, walls and sink clean. Odor affects my neighbors, and garbage is a fire hazard that attracts insects and is unsafe. No trash or garbage or any obstruction is allowed in the stairwells or hallways.
2. ___UNIT AND ROOM INSPECTION: There will be random inspection of all living units and rooms. Failure to adhere to the cleanliness policy will result in a corrective action.
3. ___MAINTAINING A POSITIVE ATTITUDE TOWARDS EVERYONE: All residences are asked to treat each other in a manner that promotes dignity, common courtesy, decency and respect. We encourage having a positive attitude toward other residents and members of the community.
4. ___PRESCRIPTION MEDICATION 1: I will report to the Resident Manager if I am taking prescription medication. I understand this will be kept in confidence. I will not withdraw from any prescribed medication without supervision of a Medical Doctor.
5. ___Residents are responsible for their medication and shall not share prescription medication with other residents. Residents who engage in the unauthorized accessing or sharing of prescription medicines will be immediately terminated from the program for unlawful distribution of prescribed pharmaceutical medication. Such Medication will be secured in a locking containment (lock box and or safe) at residents expense.
6. ___SECURITY:I will not enter my unit by any way other than the Front/Back doors. I will not give my keys to anyone (especially visitor or non-resident. If I lose my key I will report the lost key and the $20.00 cost of replacement will be at my expense. I will return any/all keys when I leave the program. I will not make copies of any keys given by Sober Solutions Transitional Housing Program. I will surrender them IMMEDIATELY upon request. I must maintain communication with the Resident Manager. If I am out of contact for more than 72 hours, I am considered terminated from the program. I will stay in the room assigned by the Resident Manager and I will not move without approval.
7. ___SMOKING: "NO" SMOKING IN UNITS. Smoking is only allowed in designated areas.
I will dispose of my cigarette butts only in ashtrays or cans.
8. ___ANIMALS: No Animals are allowed.
9. ___PROGRAM /HOUSE MEETINGS ARE MANDATORY. Program meetings will be held once a week (to be determined by location). A Corrective Action Memo will be issued for non-attendance. Exceptions are made for work, with prior written approval from the Program Manager.
10. ___RESPONSIBILITY: I am responsible for turning off lights, TV, computer and/or any electrical appliance that is not being used. Failure to do so will result in a $10.00 fine. This is a GROUP EFFORT at cost control.
11. ___CHORES: I will complete daily chores as assigned. Failure to Comply will result in a Corrective Action Memo.
12. ___ ACTIONS: Three (3) Corrective Action Memo write-ups for any reason may be cause for Termination from the program.
13. ___STORAGE: Sober Solutions Transitional Housing Program is a shared living residential recovery environment. Cabinet and Freezer space are limited.
14. ___Closet and Dresser Drawer space is also limited. Clothing and other personal items “Cannot” exceed the space assigned.
15. ___All food items/personal belongings must be marked with the name of the owner and must be taken with you when moving out, regardless if the move out is voluntary or involuntary. Sober Solutions Transitional Housing Program is not responsible for any items left behind.
16. ___Vehicles: Sober Solutions Transitional Housing Program is a shared living residential recovery environment. Residents and Guest are only allowed to park one insured vehicle on Sober Solutions property. Residents and guest are also required to have a valid Driver License in order to operate and/or park a vehicle on Property Managed by Sober Solutions.
17. ___COURTESY: Wearing appropriate attire is required at all times.
18. ___Noise Level: Noise levels should not extend beyond your housing unit. Quiet time begins at curfew.
19. ___MOVING OUT: Sober Solutions Transitional Housing Program requires a 20 day notice to vacate.
20. ___REPAIRS AND MAINTENCE: I will report any damages or repairs on a work order request and turn in to my site manager. I acknowledge that I am responsible for paying for any property damage that I cause.
21. ___GUESTS: All residents will be respectful to one another’s Guest. No overnight guests are allowed. No guests under the age of 18 are allowed in the living unit without being accompanied by an adult (Exceptions are made for biological relatives “Children” and proof of relationship must be submitted prior to visiting).
22.___ I am responsible for my guests and their behavior. Guests are only allowed in common areas and are not allowed to prepare meals. All guests must “Sign-in” and leave by curfew and will remain in the presence of the resident for whom they are visiting.
23. ___SEXUAL CONTACT: is not allowed on the premises and / or between residents.
24. ___LOANING MONEY AND THEFT: I will not loan any money to any other resident. I will not take anything without asking. Borrowing items without permission (sugar, milk etc.) is theft.
12 STEP RECOVERY INVOLVEMENTS:
Having a sponsor, support team and a relapse prevention plan is essential to one’s recovery. I acknowledge that I will prepare a relapse prevention plan, attend three (3) Sober Support group meetings per week and I will be required to show proof of my attendance at these meetings at the weekly house meetings.
I have read all items and I agree to the terms in this service agreement, I understand that Sober Solutions Transitional Housing Services operates under RCW 59.18.550 Drug and Alcohol Free Housing and Program of Recovery. The nature of this RCW provide termination of this agreement within 72hrs of a written notice to any resident who is found to be using drugs or alcohol and who refuses curb their behavior and cure the situation by obtaining professional assistance to deal with the problem with-in 24hrs of the citation. It also provide termination of this agreement within 72 hrs of a written notice to any resident who is found to be breaking any Local, State and/or Federal Laws.
I understand that D.O.C and other Housing Voucher Agencies will be notified if I am terminated for cause, if applicable. I give my permission for Manager to communicate with any and all agencies that I am involved with such as Churches, DOC, DOP, Treatment Counselors, Sponsors, Payee Services and/or Case Managers.
I hereby acknowledge that I have read, received, reviewed and understand the rules.
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Client SignatureDate
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Program Management / Assignees Date
CLIENTS QUESTIONARIE
1. Name:
2. Clean Date:
3. Drug/s of Choice:
4. Are you actively involved in a 12-Step program?
Y____ N____ If yes do you have a Home Group:
5. Do you have a Sponsor?Sponsor Name: ______
6. How many meetings do you attend a week?
7. How do you feel?
8. How do you feel about your life right now?
9. Identify Problem area/issues in your life.
10. How have you addressed these issues?
11. Do you need help with addressing or solving these issues?
12. What changes have/are you making (to your lifestyle) toward achieving a
Quality life?
13.Where do you see yourself in 6 months?
14. Will you need help in developing a strategy?
15. Are you willing and committed to the life changing strategy that you created?
Signature ______Date______