Full Treatment Application

TREATMENT APPLICATION

Step 1 of 5

PERSONAL INFORMATION

Please provide your basic personal information along with a primary contact. This information is used to process your application and ensure we have accurate contact details for both you and a trusted individual. All information provided will be kept confidential.

Name(Required)

First Last

Email Address(Required)

Birth Date(Required)

Sobriety Date(Required)

Current Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone Number(Required)

Primary Contact Name(Required)

First Last

Primary Contact Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Primary Contact Phone Number(Required)

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

ONE suitcase and ONE backpack maximum
Laptop, cell phone (will be held by staff for length of time determined appropriate by staff)*
Driver’s license or passport, social security card (can be held in safe)
Backpack / Knapsack
Resume and references
Insurance card
All prescription medication
Toiletries (alcohol-free)
Appropriate reading material (bring a Big Book, 12 Steps & 12 Traditions and Twenty Four Hours a Day if you already have them)
Musical instruments for use during leisure time
Athletic wear (t-shirts, shorts, sweatpants, etc.)
Swimming suit
$50 dollars cash ONLY (use may be restricted as determined by staff)

Things You May Not Bring

Weapons, including pocket knives
Drugs or Alcohol
More than one suitcase and one backpack of clothing
Heating pad or electric blankets
Pets
Drug paraphernalia
Clothing or other items suggestive of alcohol or drug use, promoting sexism, racism or homophobia
Valuable jewelry or expensive clothing

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 the 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.

Program Fees & Terms of Acceptance

Initial Fee of $700 Includes:

Processing
Orientation and Program Introduction
4 $50 Grocery Cards
First Month’s Housing
Utilities
Laundry detergent, paper products, cleaning supplies, hand soap

Subsequent Weekly Fee of $125 Includes:

Housing
Utilities
Urine Testing
Laundry detergent, paper products, cleaning supplies, hand soap

Roots Recovery Houses fees are non-refundable. Payment is accepted by certified cashiers check or via credit card by PayPal.

Terms of Acceptance and Signature(Required)

The applicant for residency at Roots Recovery Houses hereby warrants the truthfulness of the information provided in this application.

First Last

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

Program Standards, House Rules & Terms of Acceptance

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.

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.

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 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 10:00 p.m.

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.

Fees are $125.00 per week, if you are not paid weekly we will make the necessary adjustments.

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 Sundays. We attend many weekend events, and if you are scheduled to work Saturdays you must get the day off from work. Attendance at these events is mandatory.

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:(Required)

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.

First Last

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

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(Required)

First Last

Permanent Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Date of Birth(Required)

Age(Required)

Insured Name(Required)

First Last

Relationship to Resident(Required)

Insured Phone(Required)

Insured Date of Birth(Required)

Insured Employer

Insurance Company(Required)

Insurance Company Phone Number

Insurance ID Number(Required)

Group Number

Type of plan

Date of Coverage

TERMS OF ACCEPTANCE:(Required)

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.

First Last

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

INSURANCE INFORMATION AND DISCLOSURE

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 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.

TERMS OF ACCEPTANCE:(Required)

The applicant for residency at Roots Recovery Houses hereby warrants the truthfulness of the information provided in this application.

First Last

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

Start Your Recovery Today!

We use various evidence-based and holistic treatment modalities and provide individualized substance abuse counseling and therapy tailored to each client to ensure they achieve and maintain a life-long recovery.

Request Information

TREATMENT APPLICATION

PERSONAL INFORMATION

Health, Substance Use & Eligibility Information

Arrival Information

Personal Items

Things You May Bring

Things You May Not Bring

Program Fees & Terms of Acceptance

Initial Fee of $700 Includes:

Subsequent Weekly Fee of $125 Includes:

Program Standards, House Rules & Terms of Acceptance

HOUSE RULES

INSURANCE INFORMATION AND DISCLOSURE

INSURANCE INFORMATION AND DISCLOSURE

Start Your Recovery Today!