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Application for Admission

Last Name *

First Name *

M.I.

Date *

Phone # *

Are you on Probation or Parole? *

Yes No

Probation/Parole Officer Name

Officer Phone #

How long have you been on Probation or Parole?

Are you attending chemical dependency outpatient treatment? *

Yes No

Where are you attending outpatient treatment?

What program? (Relapse prevention, IOP, Aftercare, etc.)

Target date for completion of treatment?

Do you have a support structure (Family, Recovery Coach/Sponsor) in the Twin Falls Area? *

Yes No

When released, will you have a cell phone?

Yes No

Will you need assistance re-acquiring State or Government issued ID?

Yes No

Upon release, will you have a vehicle?

Yes No

Upon release, will you need a food box?

Yes No

Upon release, will you have access to season-appropriate clothing?

Yes No

If no, list your sizes

Shoe Size

Shirt Size

Pants Size

Application for Admission (Continued)

What are your plans for employment once released? *

Give complete treatment history *

All residents will be required to attend 12-step meetings, currently in outpatient treatment and attending meetings, or have completed a valid treatment program.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to housing, I understand that false or misleading information in my application or interview may result in my release.

Applicant Signature *

Date *

Rental Application

Last Name *

First Name *

M.I.

Date of Birth *

Phone *

Email *

Current/Previous Address

Street Address

City

State

ZIP Code

Gender

Race/Culture

Occupation

Marital Status

Previous or Current Employment

Employer

Phone

Address

City, State, Zip

Job Title

Supervisor

Responsibilities

Referred By

Additional Information

Emergency Contact

Name *

Relationship *

Phone *

Nearest Living Relative

Name

Relationship

Phone

Address

City

State

ZIP Code

Do you have any allergies? *

Yes No

If yes, please list all allergies

Preferred Location

212 4th Ave E Twin Falls, ID 83301 2091 4th Ave E Twin Falls, ID 83301 676 Shoup Ave W Twin Falls, ID 83301

I certify that my answers are true and complete to the best of my knowledge. If this application leads to housing, I understand that false or misleading information in my application or interview may result in my release.

Applicant Signature *

Date *

Consent to Release and Exchange Information

I hereby authorize Realcovery to request and/or disclose my medical records, or other various legal information, verbal or written, as identified below.

Services Requested (check all that apply)

Substance/Alcohol Abuse Services

Case Management

RSS Services (Other)

Mental Health Services

HIV/AIDS Related Information

Legal Services

Other (please specify)

I understand that my records are protected under the federal regulations governing confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as the Health Information Portability and Accountability Act (HIPAA) of 1996, 45 CFR parts 160 and 164 Subparts A and E, and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I also understand that I may revoke this consent at any time, by either written or verbal notification, except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically when the resident has moved off of the premises or was asked to leave by a manager (termination of contractual agreement).

I also understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that this agency may not condition treatment, payment, enrollment, or eligibility for benefits whether or not I sign this authorization, unless allowed by law. I understand that I may inspect or copy any information used or disclosed under this authorization.

Client Signature *

Date *

House Rules / Rental Agreement

Please read each rule carefully and check the box to acknowledge your understanding and agreement.

I agree there will be no illicit drugs or alcohol on my person, on the property or in my automobile at any time.

I agree I will not be under the influence of illicit drugs or alcohol at any time during my stay at a Realcovery facility, on or off property.

I will not have in my possession weapons of any type to include firearms, knives, explosives, or unauthorized chemicals.

Realcovery has a NO VISITOR POLICY in which only tenants of the house are allowed on the premises.

If you are not working the night shift you must be at the residence by 10:00 PM, unless pre-approved by the house manager(s).

A chore list will be posted, and you must complete your chores to the satisfaction of the house manager(s).

Your room must be clean; this includes bed made daily, laundry completed and dirty laundry in baskets, floors swept or vacuumed.

All residents will be required to attend 12-step meetings, currently in outpatient treatment and attending meetings, or have completed a valid treatment program.

There will be one house meeting per week. Your attendance is mandatory.

It is understood that any Probation or Parole Officer can enter this house and your room at any time, day, or night.

Individuals who are on Probation or Parole must attend ALL meetings required by your Probation or Parole Officer. It is the philosophy of Realcovery that individuals must be in chemical dependency outpatient treatment.

Rent will be $450 per month subject to change by owner with appropriate notification. Entire rent amount will be due upon move-in either by tenant themselves or by other approved funding agencies. Rent is NONREFUNDABLE for any reason.

Smoking/vaping is not allowed in the house. You must smoke/vape outside in a designated area.

You may be subject to random urinalysis or breath alcohol tests.

Rooms and personal vehicles are subject to random searches. Failure to allow these searches will lead to immediate termination of residency.

Failure to follow these rules will result in the resident being asked to vacate the property immediately.

Resident Signature *

Date *

Intake Application

Application for Admission

If no, list your sizes

Application for Admission (Continued)

Rental Application

Current/Previous Address

Previous or Current Employment

Additional Information

Emergency Contact

Nearest Living Relative

Preferred Location

Consent to Release and Exchange Information

Services Requested (check all that apply)

Specific Information Requested (check all that apply)

House Rules / Rental Agreement

Application Submitted