SOBER SOLUTIONS TRANSITIONAL HOUSING SERVICES PROGRAM
Consent for Services Agreement
I hereby authorize staff and volunteers at Sober Solutions Transitional Residential
Recovery Housing Services Program to provide residential recovery and reentry
related transitional services in accordance with my individual service plan.
Services will include a structured and supportive temporary living community
conducive to chemical dependency recovery and reentry policies at designated
residential property, (urine/breath analysis testing at random and/or for just
cause).
I understand that this transitional services program has a usual length of 6-12 month of stay.
I also understand that if I refuse to follow my plan and the rules set forth in this agreement which is to
stay cleanand sober, fully engaged in my designed program, as well as reporting to all care givers and
cooperate with the random and for just cause urine analysis screening. If found to be in violation of
any rule in this agreement I will receive a Corrective Memo and given 24hrs to curb and cure the
situation, if I refuse I can/will be discharged from this housing program and given 72hrs to remove my
property from the premises in according to this agreement for failure to comply.
I hereby acknowledge that I have received, read, reviewed and understand the
rules. I agree to abide by these rules and acknowledge that Sober Solutions Transitional Residential
Recovery Housing Services Program may amend them at any time in order to maintain a safe and
productive environment for recovery.
I understand that Sober Solutions Transitional Residential Recovery Housing
Services Program is not responsible for any loss, theft or damage to my personal
property during my stay. I further understand that Sober Solutions Transitional Housing Services
Program is not responsible for any injury, harm or incapacity resulting from my condition, or any action
on my part in conformance with all the rules. I agree to behave in a manner that does not inflict harm on
me or to others during my stay. I agree to hold all parties harmless.
SERVICE FEE’S
I agree to pay a one time $150 non refundable
processing fee when moving in,and a monthly service fee due
on the 1st or before the 3th day of the month.
Payments must be made by Money Order.The combined service fees for
house funds are also due on the 1st or before the 3th day of each month. The
house fee covers basic hygienic supplies, toilet paper and cleaning supplies.
I also agree to pay a $50.00 penalty if the monthly service fee is paid after the 3rd of each month. I agree
to secure either a voucher or rental assistance on or before the 1st of each month if necessary, and
beable to show proof thereof, and a promissory note MUST be signed.
Failure to provide proof of funds will result in a penalty of $50.00, and dismissal
after the 5th. I acknowledge that this service fee may be increased any time and
that I will be given a 30 day written notice. I acknowledge that there are no refunds of any fees, for any
reason no exceptions.
I also acknowledge that Sober Solutions Transitional Residential Recovery
Housing Services Program pursue collection of all money’s owed for unpaid
services and for any damage done by me to Sober Solutions Transitional
Residential Recovery Housing Services Program property.
NO TOLERANCY POLICY:
The following violations will be subject to termination :Please initial each of the following
1. ___Violating this agreement by using any drugs or alcohol regardless of
where this has occurred. This includes falsifying illnesses to obtain Prescription
Narcotic’s(Drug Seeking Behavior), will be grounds for termination.
2. ___Declining to cooperate with a drug test.
3. ___Possession of any weapons, engaging in any illegal activities and/or
associating with other persons who are engaged in illegal activities is a
violating of the policy’s set forth in this agreement.
4. ___Engaging in threats, name calling, harassment, any verbal or physical
abuse or threats thereof directed at any one involved with Sober Solutions
Transitional Residential Recovery Housing Services Program.
5. ____If I fail to pay any of the monthly service fees on time, or failing to provide
proof that I have made arrangements for financial assistance by the 3rd of
each month.
6. ____The first 14 days, I must adhere to a 9:00 pm curfew. Regular curfew is
10pm (Sunday–Thursday) 12pm (Friday and Saturday). After my 14 day
orientation period, I may spend the nights out (All DOC clients must provide
written proof from CCO’s) with prior permission from manager. I will sign out
and leave a contact number where I can be reached by the Manager.
If I sign-out for longer than 24hrs, I will check in daily. If I am ascent for three (3dy) consecutive days
without permission, the terms of my housing agreement will be considered abandon and this agreement
will terminated. Violation of the curfew period will result in a UA at the resident expense.
7. ___If this agreement is violated for any of the reasons listed above, I agree to
vacate the program within 72 hours of written notice if I failure to cure the cited
violated behavior within 24hrs. I understand that clients terminated for stated
reason(s) will not be allowed on the property for any reason after vacating. A client that is required to
vacate the property may apply to renter after completing treatment, or for visiting after 30 days.
8. ___I acknowledge that any personal belongings will be disposed of promptly after my departure upon
termination unless I make arrangement with the resident manager to return my property. Sober
Solutions Transitional Housing Services Program is NOT responsible for my personal belongings.
PROGRAM, GENERAL AND VISITOR RULES:
1. ___CLEANLINESS AND SANITATION: I acknowledge that I am required
to bath regularly, and I will wash and change the bedding weekly. I am required to
keep my living and common areas neat and clean at all times. I am also responsible for keeping the
stove, fridge, walls and sink clean. Odor affects my neighbors, and garbage is a fire hazard that attracts
insects and is unsafe. No trash or garbage or any obstruction is allowed in the stairwells or hallways.
2. ___UNIT AND ROOM INSPECTION: There will be daily inspection of all living units and rooms at 10am.
All living unit and rooms will be presentable at time of inspection (Exception for those who employment
require sleep during inspection hours). Failure to adhere to the cleanliness policy will result in a
corrective action.
3. ___MAINTAINING A POSITIVE ATTITUDE TOWARDS EVERYONE: All residences are requiring treating
each other in a manner that promotes dignity common courtesy, decency and respect. Maintaining a
positive attitude towards toward other residents and member of the community regardless of what
your recovery throw at you on your path only assist you in building character.
4. ___HARASSMENT; Harassment on the basis of race, creed, color, national
origin, age, sex, marital status, sexual orientation, and/or mental/physical disability is not permitted.
5. ___VIOLENCE;Physical Violence, Threats of bodily harm to another resident and possession of
weapons are prohibited and will result in IMMEDIATE termination.
6. ___STAY CLEAN AND SOBER:
any use of alcohol, or drugs are grounds for IMMEDIATE termination and any paraphernalia is strictly
prohibited. This is a ZERO TOLERANCE ENVOIRNMENT, and this policy is strictly enforced and
if not, It is grounds for immediate termination.
7. ___BREATH AND URINE TESTING: Random and for cause testing are routine. I am required to
cooperate and failure to do so will be grounds forIMMEDIATE termination.
8. ___PRESCRIPTION MEDICATION 1: I will report to the Resident Manager if I am taking prescription
medication. I understand this will be kept in confidence.
I will not withdraw from any prescribed medication without supervision of a
Medical Doctor.
9. ___PRESCRIPTION MEDICATION 2: I understand that any medication containing alcohol and/or
narcotics is prohibited, unless it is prescribed by a license physician and/or professional medical
practitioner. Such medications will be secured in a locking containment (Lock Box and/or Safe) at
resident expense to prevent unauthorized access in furtherance of the program’s fundamental goal
of clean and sober living. Residents are responsible for their medication and shall not share prescription
medication with other residents. Residents who engage in the unauthorized accessing or sharing of
prescription medicines will be immediately terminated from the program f
or unlawful distribution of prescribed pharmaceutical medication.
10. ___SECURITY:I will not enter my unit by any way other than the
Front/Back doors.I will not give my keys to anyone (especially visitor or non-resident. If I lose my key I
will report the lost key and the $20.00 cost of replacement will be at my expense. I will return any/all
keys when I leave the program. I will not make copies of any keys given by Sober Solutions Transitional
Residential Recovery Housing Services Program. I will surrender them IMMEDIATELY upon request. I
must maintain communication with the Resident Manager. If I am out of contact for more than 48
hours, I am considered terminated from the program. I will stay in the room assigned by the Resident
Manager and I will not move without approval.
11. ___SMOKING: "NO" SMOKING IN UNITS. Smoking is only allowed in designated areas.
I will dispose of my cigarette butts only in ashtrays or cans.
12. ___ANIMALS: NoAnimals are allowed.
13. ___PROGRAM /HOUSE MEETINGS ARE MANDATORY . Program meetings will be held once a week
(to be determining by location). A $20.00 fine will be issued for non-attendance. Exceptions are made
for work, with prior written approval from the Program Managers. Problems may be addressed at house
meetings or brought to the attention of the Program Manager as they develop.
14. ___RESPONSIBILITY: I am responsible for turning off lights, TV, computer and/or any electrical
appliance that is not being used. Failure to do so will result in a $10.00 fine. This is a GROUP EFFORT at
cost control.
15. ___CHORES:I will complete daily chores as assigned by Resident
Manager or Chore Monitor. I understand that if I fail to do my chore, I will be fined
$5.00, and I still have to complete the chore.
16. ___ ACTIONS: Three (3) write-ups for any reason will and can be cause for removal.
17. ___STORAGE: Sober Solutions Transitional Residential Recovery Housing Services Program is a
shared living residential recovery environment. Cabinet and Freezer space are limited so you are only
allowed to purchase $25.00 (Dry Goods) and $25.00 (Freezer Goods) per week.
18. ___Closet and Dresser Drawer space is also limited. Clothing and other personal items “Cannot”
exceed the space assigned. Anyone with items that exceed their assigned space will be given an
opportunity to downsize property or donate excess items to a charity of their chosen.
19. ___All food items/personal belongings must be marked with the name of the
owner and be taken with you when moving out, regardless if the move out is
voluntary or involuntary. Sober Solutions Transitional Residential Recovery
Housing Services Program is not responsible for any items left behind.
20. ___Vehicles:Sober Solutions Transitional Residential Recovery Housing Services Program is a shared
living residential recovery environment. Residents and Guest are only allowed to park one insured
vehicle on Sober Solutions property. Residents and guest are also required to have a valid Driver License
in order to operate and/or park a vehicle on Property Managed by Sober Solutions.
21. ___COURTESY: Wearing appropriate attire is required at all times.
22. ___Noise Levels;maintaining an appropriate noise, is a levels not audible
outside of the unit and/or your room is required. Sound travels and many clients
work different hours and is sleeping at different times. Being respectful of everyone right to a peaceful
living environment is appreciated and strongly encourage.
23. ___MOVING OUT: Sober Solutions Transitional Residential Recovery
Housing Services Program requests a 20 day written notice preceding the end of
the month when I plan to move.
24. ___REPAIRS AND MAINTENCE: I will report anything damaged and/or broken items to the Manager
for repair, in particular water and/or electrical problem. I acknowledge that I am responsible for paying
for any property damage that I cause.
25. ___GUESTS: All residents will be respectful to
one another Guess. No overnight guests are allowed. No guests under the age of 18yrs are allowed in
living unit without being accompanied by an adult (Exception is made for biological relatives “Children”
and proof of relationship must be submitted prior to visiting). I am responsible for my guest and their
behavior. Guests are only allowed only in common area and are not allowed to operated unit
equipmentand/or prepare meals. All guests must “Sign-in” and leave by 11pm and will remain in the
presence of the resident for whom they are visiting.
26. ___SEXUAL CONTACT: is not allowed on the premises and / or between
residents.
27. ___LOANING MONEY AND THEFT: I will not loan any money to any other
client. I will not take anything without asking. Borrowing items without permission
(sugar, milk etc.) is theft.
12 STEP RECOVERY INVOLVEMENTS:
Having a sponsor, support team and a relapse prevention plan is essential to
one’s recovery. I acknowledge that I will prepare a relapse prevention plan, attend
three (3) Sober Support group meetings per week and I will be required to show
proof of my attendance at these meetings at the weekly house meetings.
I have read all items and I agree to the terms in this service agreement, I
understand that Sober Solutions Transitional Housing Services operates under
RCW 59.18.550 Drug and Alcohol Free Housing and Program of Recovery. The
nature of this RCW provide termination of this agreement within 72hrs of a written
notice to any resident who is found to be using drugs or alcohol and who refuses
curb their behavior and cure the situation by obtaining professional assistance to
deal with the problem with-in 24hrs of the citation. It also provide termination of
this agreement within 72hrs of a written notice to any resident who is found to be
breaking any Local, State and/or Federal Laws.
I understand that D.O.C and other Housing Voucher Agencies will be
notified if I am terminated for cause, if applicable. I give my permission
for Manager to communicate with any and all agencies that I am involved
with such as Churches, DOC, DOP, Treatment Counselors, Sponsors, Payee
Services and/or Case Managers.
_____________________________________ _____________
Client Signature
Date _________________________________ _____________
Program Management / Assignees
Date
Sober Solutions Transitional Housing Services Program
CLIENTS QUESTIONARIE
1.
Name:
2.
Clean Date:
3.
Drug/s of Choice:
4.
Are you actively involved in a 12-Step program?
Y____ N____
If yes do you have a Home Group: ______________________
5.Do you have a Sponsor? _____________
Sponsor Name: ______________________
6.
How many meetings do you attend a week? __________
7.
How do you feel? _________________________
_______________________________________
_______________________________________
8. How do you feel about your life right now?
9.Identify Problem area/issues in your life
1.
2.
3.
4.
10.How have you addressed these issues?
1.
2.
3.
4.
11. Do you need help with addressing or solving these issues?
12.What changes have/are you making (to your lifestyle) toward achieving a
Quality life?
13.Where do you see yourself in 6 months?
14. Will you need help in developing a strategy?
15. Are you willing and committed to the life changing strategy that you created?
Signature _______________________Date______________