Freedom House

First Name

Middle Name

Last Name

Present Address (Street)

City

State

Zip

Are you on Probation/Parole?

YES

If yes, then please share the name and contact info of your Probation/Parole officer: Permission to communicate with them if needed?

Date of Birth

Martial Status

Married

Single

Divorced

Phone Where You Can Be Reached

Home Phone

Work Phone

Do you struggle with alcohol dependency?

YES

Do you struggle with Substance Abuse?

YES

If yes, list ALL drugs you have used addictively:

Date of last substance/Alcohol/ Drug use:

Have you previously been through a Recovery Program/Inpatient/ housing/self-help?

YES

If Yes, When and for how long?

When did you attend your first AA/NA Meeting?

How many AA/NA or Self-Help meetings do you attend weekly?

Do you currently have a sponsor/Recovery Coach?

YES

If Yes, list their name and number:

If No, do you agree to get a sponsor within 30 days of entering the Freedom House?

YES

Have you been in a treatment facility for drug or alcohol addiction?

YES

If “yes” to either, list the name, location, and primary counselor.

Are you employed?

YES

Are you receiving assistance of any type?

YES

If "yes" List your employer’s name and Number:

If Yes, what assistance are you receiving?

What is your monthly income right now?

If you do not have a employment, do you agree to find employment or seek volunteer work within 14 days of entering The Freedom House?

YES

Do you have health insurance?

YES

If “yes” Name and policy number

If “yes” to either, list the name, location, and primary councilor.

Do you take prescription medications? Opioid/ MAT Therapy is not an acceptable Recovery option at the Freedom House (other than Vivitrol)

YES

List the medications you currently take and The Doctor who prescribed them.

PLEASE SUBMIT A MEDICATION LIST COMPLETE WITH NAME OF MED AND PRESCRIBING PHYSICIAN ALONG WITH A RELEASE OF INFORMATON.

List of emergency Contacts and Numbers:

Name

Relationship

Name

Relationship

Please provide two references not related to you, with contact info:

Name and Phone

Checkboxes

YES - These people agree to be contacted to assist us with you, should any concerns arise. They are willing to come to the Freedom House to assist us in working out any concerns.

Checkboxes

YES - I realize that Freedom House has the right and will (A) prohibit all guests from using any alcohol or illegal Substances, and (B) expel any guest who violates such prohibition.

Checkboxes

YES - I have read all of the material on this application form, including the limitations set forth. I understand that The Freedom House is NOT an organization covered by HIPPA (Health Insurance Portability and Accountability Act of 1996). I have answered each question honestly and want to achieve true recovery and restoration.

Signature (type name)

Date

Failure to comply with any of these requirements will result in immediate removal from The Freedom House at the discretion of the Board and/or the guests of the house and/or the House Manager. Law enforcement will be called to assist if necessary.

I will cooperate with the House Manager, assigned to The Freedom House, and will submit to the following:

Daily Check in phone call from house landline by 10:00 pm.to the House Manager
Random visits by House Manager with interaction.
Weekly Random PBT’s and/or Drug test/screening at the discretion of the House Manager.

"I realize that The Freedom House for men, for which I am applying as a guest requires complete abstinence from Drugs and/or Alcohol. Use of Drugs and/or Alcohol is prohibited, and will result in immediate eviction from our residence(s). Disruptive and/or Discourteous behavior within our residence(s) or community will not be tolerated and can/will result in eviction from our residence(s). Finally, a guest’s inability to maintain employment and pay his/her agreed shared expenses in a timely manner can/will result in eviction from our residence(s). By initialing/signing, I acknowledge agreement to the terms stated, and hereby waive my right(s) to normal due process afforded by local landlord-tenant laws. If you are still residing at The Freedom House six months from your date of move in, you will be required submit a update of your recovery plan and submit it to the housing team.

Signature of Applicant (type name)

Freedom House Values - Please read and check

“We are free to walk out our faith in our Recovery Journey, realizing that the Freedom House and its programs utilize and encourage a Christ Centered approach."

“When personal life problems or changes occur, that may or are affecting our recovery or our stay at the Freedom House, we will keep the House Manager informed and/or Housing Team informed if appropriate to the privacy of those concerned."

“We will answer any questions The Freedom House staff or Keys to Freedom Board may have and suggest or volunteer additional information as needed.”

“We will respect each guest in the Freedom House and respect their space and property, treating each other with dignity."

"We will seek out our own resources for transportation not ‘solely’ relying on other residents and house managers to be that transportation. Carpooling is acceptable until it becomes unacceptable. It is your responsibility to get to where you need to go!"

"We will not borrow money for room fees from other residents nor will we burden community organizations for room fees, i.e. Father Fred, Salvation Army, etc. unless you have agreed to give them your time in return. If your fees for some reason become unmanageable, speak to your house manager."

GRIEVANCE PROCEDURE

TALK IT THROUGH AND WORK IT OUT, ADDING A DOSE OF HUMILITY!
IF YOU CANNOT WORK IT OUT, INCREASE DOSE OF HUMILITY!
IF THE ISSUE PERSISTS, TAKE IT TO GOD, GIVING THANKS FOR THE GOOD THINGS!
DO NOT CALL CHAPLAIN TINA! SPEAK TO YOUR HOUSE MANAGER!

FREEDOM HOUSE CODE:

WE WILL TREAT EACH PERSON WITH RESPECT AND DIGNITY UNDERSTANDING THAT WE ARE ALL MADE IN THE IMAGE OF GOD AND CHOOSE TO TREAT ONE ANOTHER ACCORDINGLY.

EACH PERSON’S PRIVACY WILL BE RESPECTED.

AS MEN OF HONOR, WE WILL LOOK OUT FOR ONE ANOTHER SETTING OUR OWN INTERESTS ASIDE.

THERE WILL BE NO ENGAGEMENT IN HARASSMENT OR DISCRIMINATION of ANY KIND OR FOR ANY REASON.

THERE WILL BE NO OFFENSIVE, THREATENING OR INTIMIDATING BEHAVIOR PHYSICALLY, EMOTIONALLY OR VERBALLY. THIS APPLIES TO ALL RESIDENTS AND HOUSE MANAGERS.

Applicants Signature (type name)

Date

If you are human, leave this field blank.

Mission for the Freedom House