Admission | Nicole's House

Name*

First Last

Inmate Number*

Phone*

Email*

Date*

Date of Birth*

Social Security Number*

Status*

Single
Divorced
Separated
Co-Habit

Age*

Current Location/Address*

Spouse/Boyfriend Name*

Spouse/Boyfriend phone

Last Address*

Street Address City State ZIP Code

Emergency Contact Name & Contact Info*

Referred by*

Number of children*

Ages*

Legal Custody*

Yes
No

Guardianship*

Yes
No

Kids' Address*

Name & Phone of current caregiver*

Are you required to pay support*

Yes
No

Amount*

Status of Family Relationships*

Support Friendships*

Education*

Job History*

Medical Insurance*

Yes
No

Provider*

Physical disabilities, chronic/ongoing conditions*

Medications*

Current STD or communicable diseases*

Mental Health Diagnosis, if any*

Inpatient psychiatric hospitalizations (please include dates)*

Suicide attempts*

When

Why

Sexual Abuse History*

Domestic Violence*

Are you in Therapy*

Yes
No

Therapist*

Phone*

Years in Addiction*

Drug of Choice*

Length of Sobriety*

List all Inpatient A&D Treatment, IOP*

List any Drug Court Orders Attendance: Dates and Phase Completed*

Self-help programs you have attended in the past*

Other

Previous Transitional or Half Way Housing*

Arrest Record

Include year

Misdemeanors

Felonies

Pending Cases

List Jail Times

List Prison Time Served

Probation

Yes
No

How long

County

Officer

Phone

Parole

Yes
No

How long

Officer

Phone

Number of Years of Prostitution

Arrests

Clean time, if any

Prostitution History (ie streets, motels, areas of town)

Are you currently incarcerated or inpatient rehab*

Anticipated discharge date*

Why Nicole's House?

Applicant's Signature

Please include a letter that recaps your addiction history, and answer two questions. 1. What is different this time? 2. How does God figure into your current plan of recovery and restoration?

General Memorandum of Understanding

Nicole’s House is a Christ centered one- year program. The culture of the house is one of kindness and grace. We apply Godly principles to each situation. Abuse and/or disrespect will NOT be tolerated. We ask before you act, speak, or respond, that you apply these three questions: Is it the truth? Is it kind? Is it helpful? During the year at Nicole’s House, I will be enrolled in and actively participate in a 10 or 12 step, faith-based step study program, and attend 3-5 weekly recovery meetings. After admission, I will secure a sponsor, and be assigned a mentor. I give permission for sponsors and mentors to discuss my sobriety and progress in the program with the leadership at Nicole’s House. If a volunteer contradicts NH rules, NH rules prevail. I will attend all scheduled in-house meetings/activities and assist at fund raising events. I will attend the Christian church of my choice at least weekly (to establish fellowship, support & teaching). I will consent to a medical exam by a doctor or APN asap. I give permission for Nicole’s House to receive medical records and/or discuss my physical and mental health with my care providers. I will provide RX proof and pay for all medications. I am responsible for self-medication and storing said meds in a safe place. I will notify leadership if/when I have medication changes, start or stop taking medications. I will not share medication, and I will not be able to take any RX meds that would present a positive drug result. Upon admission I will work with volunteers to obtain a birth certificate, social security number, food stamps (to be shared at Nicole’s House), driver’s license reinstatement, ID, and/or medical insurance, etc. I am responsible for paying (on time) any fines, child support, medical bills, probation and/or parole fees, and the cost of securing a birth certificate, ID or Driver’s license. I will surrender my cell phone and refrain from or delete social media for a minimum of the first 30 days, I will erase all contacts that are related to addiction. Once I have a phone, I will shut down my cell phone from 10 p to 6a each day. I will get permission before using house computers and phone. I will not communicate in any way with anyone who is incarcerated. I can make/receive one call per week to family. I will be employed within the first 45 days of my residency here. I will not work more than 24 hours per week; for at least the first nine months of the program. I will begin paying program fees of $300 per month no later than my 60th day of residency. I will create and abide by a set spending and savings budget. I will accept and perform all housekeeping, meal prep and kitchen duties. This also includes yard work, taking out the trash, running & unloading the dishwasher, etc. I will handle all appliances responsibly. I will actively contribute 4-8 hours per month towards any sustainability or $$ raising projects the house may have implemented to generate income for Nicole’s House. I will set goals, earnestly work towards achieving those goals and meet weekly with my case manager regarding the status of my progress. My financial status may be reviewed monthly. At times, these meetings may also include my mentor, therapist, etc. I will submit to random drug screens. Use of drugs or alcohol will result in being discharged from the program, and the house. Suspicion of drug use or theft will result in searches of my bedroom, my person, and personal property. While here, I become a mandated reporter to the house leadership. I will notify leadership if other residents use drugs, drink alcohol, steal, plan to vacate without notice, destroy property, or become a danger to themselves or others. Failure to do so may result in my termination from Nicole’s House. Nicole’s House is a smoke free facility, property and program. No exceptions. An employer may ask me to hide some piercings or tattoos while at NH. While there will be no condemnation for them, I will not get tattoos or piercings while enrolled in this one-year program. If allowed, family member visits will be at NH for a minimum of the first 90 days. We are a safe site for children to visit. Arrange times with house leadership, so as not to interfere with other house activities. No dating of either gender is permissible during your journey at NH I will report my appointments and work schedule on the group calendar. I will sign out when leaving the home and call if there are unexpected changes to my schedule. I will notify leadership if I need transportation. I will abide by the 10 p.m. curfew. I will respond timely to all texts, phone messages. If I have a vehicle, I will have it properly registered and insured. I am responsible for gasoline and repairs. I will use street parking. I will not abandon vehicles requiring major repair work. I will practice good hygiene – I will brush my teeth and bathe daily. I will launder clothes, linens and replace bedding each week. I will not flush tampons, pads, facial tissue or wet wipes down the toilet. I understand that I will share a closet, and I will be respectful of others’ personal items and clothing. NH is not responsible for lost or stolen property. I will be responsible for the cost to repair any damage I incur to the property, furniture, furnishings, etc. I will replace anything that I have stolen.. I will not disclose the physical address of Nicole’s House. Other than DHS, Medical Insurance, my bank, the courts, probation or parole, I will receive mail at: P O Box 44, Avoca, AR. 72711. In the last quarter of my time here, I will work towards finding my own home. **With your success and best interest at heart, any activity, behavior, or relationship that potentially interferes with, or takes your focus away from your successful completion and compliance with the program will not be acceptable. This includes but is not exclusive to any form of dating or pursuit of romantic interests, engaging in family drama, or other negative outside influences. If it is deemed that such circumstance exists or is observed, it will be addressed by a member of NH Leadership and a proposed written reconciliation path laid out. Immediate compliance with the reconciliation path must take place and continued adherence observed to stay in the program. This could include but is not limited to immediately stopping or cutting off of all communication with an outside individual potentially jeopardizing your success, reassignment of mentor, sponsor, church or recovery group where unhealthy codependency may occur, etc.”

Signature*

Name*

Witness Signature*

Witness Name*