Jamie's Cottage | Keys to Freedom Ministries

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

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 been through a recovery program/housing/self-help?

YES

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

YES

If Yes, which Recovery Home

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?

Do you have health insurance?

YES

If “yes” Name and policy number

Phone Where You Can Be Reached

Home Phone

Work Phone

When did you attend your first Recovery Meeting?

How many Recovery 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 Jamie’s Cottage?

YES

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

What is your monthly income right now?

If you do not have a job, or do not receive assistance; do you agree to get a job or seek volunteer work within 14 days of entering Jamie’s Cottage?

YES

Do you take prescription medications? M.A.T. is Not an acceptable Recovery option at Jamie’s Cottage (other than Vivitrol)

YES

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

Medicaid?

YES

Do you have a Primary Care doctor?

YES

If “yes” name and phone number

Do you have a Drivers License?

YES

If Yes, do you have a Vehicle with current registration and Insurance?

YES

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 Jamie’s Cottage to assist us in working out any concerns.

Checkboxes

YES - I realize that Jamie’s Cottage has the right and will (A) prohibit all guests from using any alcohol or illegal drugs, and (B) expel any guest who violates such prohibition.

Checkboxes

YES - I have read all the material on this application form, including the limitations set forth. I understand that Jamie’s Cottage 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

Jamie’s Cottage Values - Please read and check

“When problems or changes occur, we will keep the Keys to Freedom Board/House Manager and Jamie’s Cottage guests posted as quickly as possible.”

“We will be cooperative with the Board/House Manager and Jamie’s Cottage guests, but our primary responsibility is to communicate directly to those most directly affected by our actions as soon as possible.”

“We will respect and seek to work with each Jamie’s Cottage guest.”

Failure to comply with any of these requirements will result in immediate removal from Jamie’s Cottage at the discretion of the Board/House Manager and your Judicial Supervisor. Law enforcement will be called to assist if necessary

That I will cooperate with the following:

Sunday thru Saturday check-in calls from house line by 10:00 pm.
Random daily visits by House Manager with interaction.
Weekly Random PBT’s and/or Drug test/screening at the discretion of the House Manager. (Appropriate with Probation/Parole guidelines.)

"I realize that Jamie's Cottage for Women, for which I am applying as a guest requires complete abstinence from Drugs and/or Alcohol. Any use of Drugs and/or Alcohol is strictly prohibited and will result in immediate eviction from our residence(s). Disruptive and/or Discourteous behavior within our residence or community will not be tolerated and can/will result in eviction from our residence. Finally, a guest’s inability to maintain employment and pay her agreed shared expenses in a timely manner can/will result in eviction from our residence. 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. Also, if you are still residing at Jamie’s Cottage 6 months from your date of move in, you will be required to submit a request for additional time at Jamie’s Cottage and a written review of your Recovery Progress.

Signature (type name)

Date

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Jamie’s Cottage

Mission for the Jamie’s Cottage