Admit Date: ____________________
On this day, this Agreement is between Empowering Potential Housing
General Services Provided: Empowering Potential Housing Benson house is for women ages 18 and older with a chemical dependency and a disease of addiction. Empowering Potential Housing provides a home-like atmosphere and environment to enhance sober living skills.
Empowering Potential Housing provides the following general services:
Family Resident’s General Responsibilities: Family Resident agrees to make a minimum ninety-day (90) commitment of residency and provide at least thirty-day (30) notice prior to leaving. In addition,
Family Resident is required to accept the following general responsibilities:
Family Resident Discharge: Upon discharge from Empowering Potential Housing Sober Living, Family Resident agrees to leave the premises, property, and facilities immediately. Family Resident agrees not to return to the premises, properties, or facilities of Empowering Potential Housing or contact other Family Residents at the facility, without written permission from the Operator. Family Resident understands Empowering Potential Housing shall have the right to discharge and require the Family Resident to leave the facility immediately for not following the Cardinal Rules:
Personal Property: Empowering Potential Housing reserves the right, at its sole discretion and determination, to deny certain personal items into the facility on the basis that they are inappropriate, dangerous, problematic, or take up too much space. Any clothing or other personal items that cannot be stored neatly in provided closets, drawers, or shelves are not permitted. Personal furniture without prior approval is not permitted. Off-street parking is provided as available, and Family Resident agrees not to own or maintain more than one vehicle in neighborhood. Pets are not permitted. Family Resident will refrain from harboring, feeding, or allowing any animal inside, outside or about the premises.
Inspection of Personal Items: Family Residents grant to Empowering Potential Housing permission to inspect, at any time, all belongings, personal items and general living space for any liquor, drugs, or drug paraphernalia, weapons, or items determined by Empowering Potential Housing to be dangerous or inappropriate. In addition, Family Resident grants Empowering Potential Housing permission to remove and dispose of any such items found during inspection.
Removal of Personal Property: Upon discharge, Family Resident agrees to remove all personal property immediately. Family Resident understands and agrees Empowering Potential Housing may dispose of all personal property left on the premises for 24 hours following discharge. Upon discharge, Family Resident is encouraged to submit change of address to the U.S. Postal Service. Empowering Potential Housing assumes NO responsibility for mail delivery and Family Resident understands mail will not be held or forwarded on their behalf.
Room Assignments: Family Resident agrees to comply with room assignments.
Drug Testing: Family Resident understands and agrees Empowering Potential Housing may perform breathalyzer, swab, and or urine testing at any time with or without cause. Family Resident agrees to submit to the testing process and procedures.
Facility and Furnishings: Furniture, window coverings and other room amenities may not be moved or rearranged. Family Resident may not attach anything to windows, doors, walls, furnishings, or any other part of the facility. Family Resident agrees to immediately assume the full cost of replacement or repair to facility, equipment, and furnishings caused by accident, misuse, or negligence.
Liability: Family Resident will hold Empowering Potential Housing Recovery Residences, employees, management, house mom/senior resident, and volunteers harmless and free from all liability for losses through fire, theft, or personal injury while in, on, or about the premises, property and facilities and/or while being provided transportation and/or while participating in any activities both inside and outside the premises, property and facilities of Empowering Potential Housing Recovery Residences.
Personal and Medical Information: Family Resident grants permission to any doctor, hospital, institution, or attorney or agency to provide all personal and/or medical information to Empowering Potential Housing Recovery Residences.
Nondiscrimination: Empowering Potential Housing does not discriminate, nor will permission be denied based on ethnic group identification, religion, age, sex, color, or disability.
Registration Requirements: Prior to admission or upon any subsequent notice, Family Resident agrees to disclose Empowering Potential Housing any law enforcement registration requirements such as PC290, or any other registration requirements. Failure to disclose such requirements are grounds for immediate termination. In accordance with Empowering Potential Housing policy and state law, PC290 registrants are prohibited from enrolling or participating.
Reporting Requirements: Family Resident understands that in compliance with federal, state, and local laws Empowering Potential Housing is required to report to the appropriate authorities, all incidences of child abuse, elderly abuse and harm to self or others. Furthermore, Family Resident understands and agrees progress reports may be given to the Court Officials, Parole and Probation Departments, if applicable as required or requested.
Program Fees and Payment Schedule: The monthly fee is______________________ dollars + _________ dollar non-refundable move-in fee. Unless special financial provisions are agreed upon below, the total monthly fee is due immediately upon admission and on the same day each subsequent month. Program fees are due in advance and are non- refundable.
Late Fees: A late fee of $25.00 will be assessed to any account that is not paid in full by the 3rd of each month following the due date.
Utilities: Utilities are included as part of the program fees paid. Included utilities are limited to gas, electricity, water, sewer, internet, landline and rubbish.
House Fund: Family Resident is responsible, along with other house members, for an equal portion of any house fund established by house members to cover Incidental household bills and expenses. House fund fees are non-refundable. EMPOWERING POTENTIAL HOUSING IS NOT RESPONSIBLE FOR ANY HOUSE FUNDS.
Refund Policy: All program monthly and move it fees are non-refundable. Family Resident understands that if discharged for non-compliance with this agreement, or if Family Resident voluntarily leaves for any reason without thirty-day (30) notice, or Family Resident fails to be admitted on scheduled admission date for any reason, Family Resident will not automatically receive a refund for any fees paid. If bed is filled, Empowering Potential Housing may refund a prorated fee from the date a new resident takes the bed.
Special Financial Provisions (must be pre-approved by Empowering Potential Operator):
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Special Conditions:
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Acknowledgement of Terms and Receipt: My signature below, as Family Resident, indicates that I have read, or had read to me and explained the provisions of this Agreement. I agree to and will comply with all the terms, provisions, and conditions of this Agreement. Further, I acknowledge the receipt of a copy of this agreement.
**I UNDERSTAND THAT I AM CONSIDERED A GUEST IN THIS HOUSE, AND FORFEIT ALL TENANT RIGHTS UPON SIGNING OF THIS CONTRACT**
FAMILY RESIDENT:
Print name_______________________________________________
Signature________________________________________________
DATE__________________________________
HOUSE MOM/SENIOR RESIDENT/OPERATOR:
Signature _______________________________________________
DATE______________________
HOUSE RULES
(RED TYPE = IMMEDIATE REMOVAL FROM HOME)
You are in a Recovery Residence. Your success and continuance in this environment are dependent upon your consistent good behavior and cooperation. Disruptive and/or discourteous behavior will not be tolerated. Any contact with Illicit drugs and/or alcohol and/or violation of any of the following rules may result in dismissal. Your signature below indicates your understanding and agreement to abide by these rules.
SAFETY:
_____No loitering or hanging out in the front yard for any reason. The back patio is used for this.
_____Keep entry and exit doors closed and locked at all times.
_____Knives, Guns, Tasers, Brass knuckles, any other weapons, drugs or paraphernalia etc. are not permitted AT ANY TIME! If found, items will be removed, and dismissal may be issued.
_____Medication should always locked away - excluding when it is time for self-administration. You must immediately return medication to locked container following self-administration.
_____Do not leave items on the floor that may cause a slipping or trip hazard.
_____Everyone entering the home needs to sign in and out on the log white board – guest use the paper sheets in white binder.
_____No (lit) candles, incense, or fires (even in fireplaces) except for decoration.
_____Do not lock or block doors – bathroom door is fine but note we will check on you if extended time.
BEHAVIOR:
_____No aggressive or violent behavior EVER!
_____No profanity or offensive language directed or romantic advances on others in home.
_____No sex of any type anywhere in/near/or by the home.
GENERAL:
_____House Mom/Senior Resident (house mom/senior resident) may inspect in and around bedroom property or belongings at any time and within reason, for the safety and protection of all residents.
_____Do not steal or use another person’s items without permission.
_____Do not open or enter any cabinets or closets with locks.
_____Turn lights/TV/fans off when not in use.
_____You may NOT enter another resident's room at any time.
_____Keep bedroom doors always closed.
_____Clothes and shoes/slippers must be worn outside of your room.
_____Never leave personal items unattended in common areas.
_____If you are diabetic or need to give yourself shots using a syringe, you will need to have a medical grade bin to dispose of used needles properly.
_____Sleeping in common areas is prohibited.
_____Thermostat is to be adjusted by the House Mom/Senior Resident only (76 summer AC/68 winter heat)
_____House Meetings are held every Saturday from 9am -10am (or modified by House Mom/Senior Resident) and are mandatory for every resident. Prior to house meeting is a 2 hour “double scrub” of the house which is also mandatory.
CURFEW:
_____First 14 days in home curfew is 11 pm every night.
_____After 14 days in home curfew is midnight daily and 1am Friday and Saturday. Failure to return to the house on time can/will result in dismissal.
_____House quiet time is 10:00pm to 7:00am. Any activity (i.e., Lights, TV, phone conversations, food prep etc.) that disturb another resident’s ability to sleep/rest is prohibited.
OVERNIGHT PASS/GUESTS:
_____Overnight/weekend passes are to be submitted to the 619-500-3987 + House Mom/Senior Resident a text thread at least 24 hours in advance with a returned reply “approved” or “okay” before you leave. You must be in compliance with house rules before approved.
_____Adult guests are only allowed in the backyard of the home to visit:
2 hours Monday-Friday 6pm - 8pm
2 hours or less Saturday-Sunday noon – 8pm
_____Children (age 17 or less) are allowed to visit:
2 hours Monday-Friday 10am - 8pm
6 hours or less Saturday-Sunday noon – 8pm kids ages 12 and less are allowed in the common areas of the home along with backyard.
_____Animals are NOT allowed due to other participant allergy concerns, flea infestations, sanitary issues or the general safety of others.
SMOKING, ALCOHOL, AND DRUGS:
_____Consumption or possession of alcohol in any form is strictly prohibited.
_____Use or possession of illicit drugs in any form is strictly prohibited.
_____Use and/or possession of drugs and/or alcohol on site will result in immediate dismissal.
_____Lying, cheating, and stealing are strictly prohibited. If caught, will result in immediate dismissal.
_____All are required to submit to a drug and alcohol test at any time as per request. A refusal and/or failure to provide an adequate sample will be treated the same as a positive test result. Any attempt to cheat/circumvent a test will result in a dismissal.
_____Smoking/vaping inside the home is strictly prohibited. Smoking/vaping is allowed in a back patio area away from door, windows and play spaces except during quiet hours of 10p-7a. This is a smoke free residence.
DAILY HABITS:
_____Daily attendance at a Recovery meeting is strongly encouraged; the minimum daily attendance requirement is 4 per week (if sober less than 6 months) or 3 per week (sober 6 months or longer) and will be tracked.
_____Attendance Saturday 7a-10a for cleaning and house meeting is mandatory!
_____You are encouraged/recommended to maintain a Home Group.
_____You are required to maintain a working relationship with a Sponsor or Therapist.
_____You are required to maintain employment or go to scl. If at any time you become unemployed or not enrolled in school and you’re capable of working (not injured or sick), you’re required to actively seek employment from 9:00 am - 5:00 pm Monday through Friday. Your employment is prohibited from interfering with their adherence to any of the other terms of this agreement.
_____Behavior considered to be a “conflict of interest” (i.e., sponsorship, employment, dating, etc.) between residents is prohibited.
CLEANLINESS:
_____Put trash in the trash can, wash dirty dishes and put in dishrack, clean up after you use the bathroom, make your bed, put up your clothing and items
_____Your room shall be kept in an orderly and sanitary condition at ALL times – wash bedding 1x per week.
_____Food is only to be consumed in the dining room areas only. Food is NOT ALLOWED in bedrooms at any time. No dishes left in the sink and wipe down counters, stove, etc. of your mess.
_____If you spill anything or make a mess anywhere in the house including your room, you will be responsible for cleaning it up.
_____Kitchen appliances, counter-tops, utensils, dishes, pots, pans, etc. will be cleaned and returned to their respective place (immediately) after each use.
_____Refrigerator – All food must always be covered or be put in a storage container.
_____Chores are required to be completed daily. The House Mom/Senior Resident is responsible for chore assignment and completion. Failure to complete assigned chores can result in dismissal.
_____A good general clean-up of all areas inside and outside the home is required at all times.
YOUR ROOM:
_____You may NOT enter another resident's room at any time.
_____Mattress covers must NEVER be removed.
_____Keep bedroom doors closed and personal items inside of your room (valuable Items should be secured).
PERSONAL HYGIENE:
_____Tampon, sanitary pads, adult diapers, etc. must be wrapped in tissue or a bag and placed in trash receptacles properly.
_____You shall keep up with your personal hygiene by bathing and brushing your teeth frequently along with putting on clean clothing and wearing footwear while in the common areas.
_____You shall have no complaints that you or your personal space has offensive odors.
_____You will take responsibility for their own health and respect the health and safety needs of all other residents and will take precautions (hand washing, extra cleaning of surfaces, limiting interaction with other residents, appointment with a physician if necessary) when aware of or experiencing exposure to bodily fluids and communicable disease
LAUNDRY:
_____Use of Laundry may be on scheduled day and time ONLY.
_____Laundry area must be clean and all clothes must be removed daily.
_____You may not wash another person’s clothes.
_____You may not put feces soiled items into any washer or dryer in the home.
_____You agree to each of the following (check all that apply):
[ ] Work, go to school, or volunteer outside of the residence
[ ] Participate in mutual aid or caregg
[ ] Participate in social, physical or creative actives
[ ] Participate in daily or weekly community activities
Rules are subject to change at any time and can be modified by management to accommodate different situations.
No possessor rights are granted or intended by this agreement. In the event the resident is unable to abide by the policy and rules, by my signature below, you agree to immediately vacate the property.
My signature signifies that I have read and understand what I can and cannot do while living in Empowering Potential Housing. I understand and agree that if I break any rules within this document in red type, my stay will be terminated immediately, and I will be banned from living in other homes that Empowering Potential Housing manages.
Print Name__________________________________________________________
Signature: _______________________________________ Date: ___________________
House Mom/Senior Resident/Operator Print Name ________________________________________
Signature: _______________________________________ Date: ___________________