Personal Information
Applicant Name *
Applicant Name
Birth Date *
Birth Date
Sobriety Date *
Sobriety Date
Current Address
Current Address
Phone Number *
Phone Number
Primary Contact Name *
Primary Contact Name
Primary Contact Address
Primary Contact Address
Primary Contact Phone Number *
Primary Contact Phone Number
Terms of Acceptance and Signature *
Terms of Acceptance and Signature
The applicant for residency at Roots Recovery Houses hereby warrants the truthfulness of the information provided in this application.
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Arrival Information
Personal Items
Upon arrival at Roots Recovery Houses all property will be searched and inventoried. This is done to keep the residents and the community safe. Items that are inappropriate will be held in the safe, disposed of or donated to charity
Things You May Bring
Things You May Not Bring
Note: any and all personal belongings left on the premises of Roots Recovery Houses LLC for more than 24 hours after voluntary or involuntary discharge from the Roots Recovery program become property of Roots Recovery Houses LLC and by signing below I give Roots Recovery Houses LLC permission to dispose of these items however they see fit. By signing below I also agree that any theft, loss, or damage of any kind to any personal property is not the responsibility of Roots Recovery Houses LLC, and that I will not hold Roots Recovery Houses LLC responsible. Items of personal or monetary value should not be brought to the facility.
FEE SCHEDULE
Initial Fee of $700 Includes:
Subsequent Monthly Fee of $500 Includes:
Roots Recovery Houses fees are non-refundable. Payment is accepted by certified cashiers check or via credit card by PayPal. Applicants must arrange their own transportation to Roots Recovery Houses. The first month’s fee may be paid by a family member. After the first month, all residents are required to pay all of their own fees.
Terms of Acceptance and Signature *
Terms of Acceptance and Signature
The applicant for residency at Roots Recovery Houses hereby warrants the truthfulness of the information provided in this application.
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COMMUNITY STANDARDS
Honesty, integrity, discipline, and service are the foundation of the Roots Recovery program. All residents must strive to represent these tenets in their daily life. Living a sober life is about more than finding freedom from addiction, it is about developing and maintaining a personal moral code.
Racism, sexism, homophobia, or any comments, attitudes, and / or behaviors that are derogatory towards any group or individual are not acceptable in any context or circumstances at any time, and are grounds for expulsion.
Any behavior that constitutes bullying as determined by the Roots Recovery community is grounds for immediate expulsion.
Roots Recovery Houses require a 6 month commitment, this program is not a month-to-month living situation. If a resident decides that they do not want to complete the entire six-month program, they must leave immediately.
Contact with family, friends, or significant others is suspended for a minimum of 30 days. This restriction will be lifted at the discretion of the house manager based on the resident’s progress and may last longer than 30 days. Family and friends are expected to adhere to this restriction. Family members, friends, or significant others who break this restriction may cause the resident’s expulsion from the program.
Residents must participate in a 12 step program AND the Roots Recovery community. This includes but is not limited to; attendance at a minimum of 1 outside 12 step meeting per day on workdays and 2 on any days off, acquiring a sponsor within 1 week of arrival, working all of the twelve steps, becoming a participating member of a home group, actively making 9th step amends between months 3 and 6, volunteering and maintaining service commitments.
HOUSE RULES
Roots Recovery Houses have limited storage space for each resident. Do not bring more than one carry-on sized suitcase and one backpack worth of personal belongings. Residents who arrive with more than the allowed amount of belongings will need to make immediate arrangements to transport any excess off the premises.
Cell phones, laptops, cars, dating, and social media are privileges that must be earned. Failure to uphold the Roots Recovery Houses Standards may result in the loss of these privileges at any time, regardless of the resident’s length of time in the program.
Residents are not permitted to attend school. They must focus completely on the work of recovery.
Cell phone usage is restricted for a minimum of thirty days and is contingent upon regular employment. This restriction will be lifted at the discretion of the house manager based on the resident’s progress and may last longer than 30 days.
No library or computer usage for a minimum of 30 days except supervised employment search. This restriction will be lifted at the discretion of the house manager based on the resident’s progress and may last longer than 30 days.
No romantic contact including Facebook, phone, notes, etc. until you have been in the house a minimum of 60 days. This restriction will be lifted at the discretion of the house manager based on the resident’s progress and may last longer than 60 days.
No car for a minimum of 60 days. This restriction will be lifted at the discretion of the house manager based on the resident’s progress and may last longer than 60 days.
Follow any and all other rules as updated by staff.
Complete individually assigned chores at designated times.
Proper personal hygiene is mandatory.
Proper clothing must be worn at all times and will be determined by staff.
No new tattoos or piercings.
No pornography of any kind.
No physical altercations.
Noise levels will be kept to a reasonable level determined by staff. No instruments or music after 10:00pm.
Curfew is 11:00 p.m. Sunday through Thursday and 12:00 a.m. Friday and Saturday.
Be respectful of our neighbors.
Refusal to complete any drug screening is cause for expulsion.
All residents must attend the house meeting nightly Monday through Friday.
Roots Recovery community residents must pay their own way after the first month. All residents must find a job and work a minimum of 30 hours per week.
You will sleep on the couch until you find a job.
Fees are $125.00 per week, if you are not paid weekly we will make the necessary adjustments.
Family may pay only the initial admission fee of $700.00. No additional financial support or aid from anyone is permitted during your stay at Roots Recovery Houses.
Paid “side-work” (yard work, painting, etc.) is only permitted for residents who already have regular employment. Commissioned jobs are not permitted.
Residents may not work on Saturday or Sunday, Saturdays are optional during the winter months, but during the summer (June through September) we attend many events and you will be required to go, even if it means losing your job.
Groceries are not included, residents will be provided with four $50.00 grocery cards for the first month, after that they will pay for their own food.
Failure to fully disclose any prescription medication, or the use of any prescribed medication not in accordance with the stated directions is grounds for immediate expulsion.
All personal items must be removed from the premises within 24 hours of completing your stay at Roots Recovery Houses LLC.
TERMS OF ACCEPTANCE: By signing below I state that I understand that failure to uphold any and all of these standards may result in expulsion from the program and forfeiture of all fees paid to Roots Recovery Houses LLC. *
TERMS OF ACCEPTANCE: By signing below I state that I understand that failure to uphold any and all of these standards may result in expulsion from the program and forfeiture of all fees paid to Roots Recovery Houses LLC.
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Insurance Information and Disclosure
Many residents choose to seek medical, therapeutic or other services covered by health insurance while enrolled in the Roots Recovery Houses sober living program. Please provide insurance information so that we can assist the applicant if they choose to seek or have need for medical or psychiatric help while living at Roots Recovery Houses.
Resident Name *
Resident Name
Permanent Address *
Permanent Address
Date of Birth *
Date of Birth
Insured Name *
Insured Name
Insured Phone *
Insured Phone
Insured Date of Birth
Insured Date of Birth
Insurance Company Phone
Insurance Company Phone
Date of Coverage
Date of Coverage
TERMS OF ACCEPTANCE: By signing below I, (Insured Named Below), agree that the above information is correct and valid to the best of my knowledge and hereby give Roots Recovery Houses permission to provide this information to any and all health care providers in the event that the resident is attempting to obtain services or where services have been rendered. *
TERMS OF ACCEPTANCE: By signing below I, (Insured Named Below), agree that the above information is correct and valid to the best of my knowledge and hereby give Roots Recovery Houses permission to provide this information to any and all health care providers in the event that the resident is attempting to obtain services or where services have been rendered.
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Signatory and Financial Terms and Conditions
By signing below I agree that I have read and fully understand all of the above information. I assert that I have read and understand all admissions requirements, house standards, drug testing policies, housing fees and non- refundable fee information. I affirm that all information supplied by myself is true and accurate to the best of my knowledge.
I understand that Roots Recovery Houses LLC is not responsible for relapse. I understand that Roots Recovery Houses LLC is not a treatment center and does not have 24 hour staffing, counseling, or medical staff. I understand that Roots Recovery Houses LLC methods are not guaranteed, and that relapse is a common outcome in which Roots Recovery Houses LLC is not to be held responsible.
I agree that any and all personal belongings left on Roots Recovery Houses premises for more than 24 hours after a resident is discharged or decides to leave the program for any reason become property of Roots Recovery Houses LLC, and by signing below I agree that Roots Recovery Houses LLC has the right to dispose of said belongings in any way they see fit.
I also agree that I will not hold Roots Recovery Houses LLC legally, morally, financially, or in any other form responsible for anything that occurs while taking part in the program, or anything that happens to any resident or is done by any resident at any time for any reason. I understand that Roots Recovery Houses LLC is not responsible for lost or stolen property.
I agree that any and all payments made in any fashion by anyone listed on this application or for anyone listed on this application to Roots Recovery Houses LLC are 100% non-refundable.
I understand that Roots Recovery Houses LLC reserves the right to ask any resident to leave at any time for any reason with or without just cause. I understand that residents will not be under total supervision and that residents will never be restricted from leaving the facility.
I understand and agree that Roots Recovery Houses LLC and anyone affiliated with them at the time of incident, employed or not employed by Roots Recovery Houses LLC, is not responsible for any injury, death, or harm done to any resident or by any resident. I agree and understand that Roots Recovery Houses LLC is not a treatment center or a facility that is licensed by any state to provide therapy or treatment to residents for any reason. Roots Recovery Houses LLC is a community-based sober living program.
Applicant Signature *
Applicant Signature
TERMS OF ACCEPTANCE: The applicant for residency at Roots Recovery Houses hereby warrants the truthfulness of the information provided in this application.
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