Today's Date
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MM
DD
YYYY
Referring Agency
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Why are you looking for housing?
Give details for problem or symptoms. Note clean time, length of time homeless or current living status.
How many times in recovery?
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Have you been in a residential treatment program?
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Yes
No
Have you been in outpatient recovery program?
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Yes
No
Please explain recovery answers.
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What is your planned activity while attending this housing program?
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Who/Whom will be your support?
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Do you have a work history?
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Please describe any Trauma issues.
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What is your ultimate goal while staying with us?
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Name
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First Name
Last Name
Social Security Number
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Date of Birth
MM
DD
YYYY
A.K.A.
Clean Date
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MM
DD
YYYY
Referred from?
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First Name
Last Name
Phone number
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(###)
###
####
Race/ethnicity
Sexual orientation
Marital status
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Disability status
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Do you receive foodstamps?
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Yes
No
Doctor name
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First Name
Last Name
Doctor address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Doctor phone number
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(###)
###
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Allergies (please list)
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if you have no allergies, simply write "none"
In case of emergency, please list your preferred hospital
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Emergency contact 1
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First Name
Last Name
Emergency contact 1 phone
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(###)
###
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Relationship to emergency contact 1
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Emergency contact 2
First Name
Last Name
Emergency contact 2 phone
(###)
###
####
Relationship to emergency contact 2
Emergency contact 3
First Name
Last Name
Emergency contact 3 phone
(###)
###
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Relationship to emergency contact 3
First child name
First Name
Last Name
Child 1 date of birth
MM
DD
YYYY
Mother of this child
First Name
Last Name
Age of mother of this child
Father of this child
First Name
Last Name
Age of father of this child
Who has custody of child 1?
First Name
Last Name
List any known allergies of this child
Second child name
First Name
Last Name
Child 2 date of birth
MM
DD
YYYY
Mother of this child
First Name
Last Name
Age of mother of this child
Father of this child
First Name
Last Name
Age of father of this child
Who has custody of child 2?
First Name
Last Name
List any known allergies of this child
Third child name
First Name
Last Name
Child 3 date of birth
MM
DD
YYYY
Mother of this child
First Name
Last Name
Age of mother of this child
Father of this child
First Name
Last Name
Age of father of this child
Who has custody of child 3?
First Name
Last Name
List any known allergies of this child
Fourth child name
First Name
Last Name
Child 4 date of birth
MM
DD
YYYY
Mother of this child
First Name
Last Name
Age of mother of this child
Father of this child
First Name
Last Name
Age of father of this child
Who has custody of child 4?
First Name
Last Name
List any known allergies of this child
1. I agree to get up each morning, no later then 7am Monday thru Friday, to prepare the day for myself.
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2. I agree to attend all house meetings.
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3. I agree to clean my room/unit prior to leaving the house.
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4. I agree to complete chores in the mornings and afternoons to help keep the facility clean and safe.
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5. I agree to plan and prepare nutritious meals for myself.
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6. I agree to have meals prepared on time.
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7. I agree to inform staff when I am leaving and returning.
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8. I agree to honor the curfew unless I have received permission from the staff to return after curfew. Curfew is as followed:
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Curfew - Sunday thru Thursday, clients should be in the house no later than 9 p.m., lights out by 11.p.m.; Friday and Saturday, clients should be in the house no later than 10 p.m., all lights out by 12 a.m.
ALL CURFEWS ARE SUBJECT TO ADJUSTMENTS
9. I agree to have something positive to do during the day, school, working, volunteering, job search, etc.
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10. I agree to pay monthly payments on the 1st of each month. Payments are due before the 5th of each month unless other arrangements are made.
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11. I agree not to verbally, physically, or sexually harass or abuse anyone in the house. I understand that violation of these rules could result in being asked to leave and will not be reimbursed for days remaining.
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12. I agree to attend all house meetings. House meetings are mandatory. Not attending a house meeting can result to being ask to leave.
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13. I agree not to use racist, sexist, or homophobic language. I understand that violation of these rules may result in being discharge.
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14. I agree not to use drugs or alcohol while living at Change To Come. I will not frequent establishments (bars) or residents that serve drugs or alcohol.
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15. I agree to smoke cigarettes, cigars or pipes in restricted areas only.
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16. I agree not to bring drugs, weapons, alcohol, or related paraphernalia onto the premises. I understand violation of these rules will lead to discharge and will not be reimbursed for remaining days.
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17. I agree to put all medications up at all times, no exceptions.
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18. I agree to not take belonging from other clients without their permission.
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19. I agree to speak to staff before harming myself, others, or my child / children.
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20. Fighting is not allowed and will result in an automatic discharge.
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I understand and agree to abide by the rules of Change To Come. Failure to keep these rules may result in termination from this housing facility.
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