Client Application Forms Oasis House for Women A Substance Abuse Program and Clean Living Environment

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1 Client Application Forms Oasis House for Women A Substance Abuse Program and Clean Living Environment General Information Letter PLEASE READ CAREFULLY (7-06) Business Office: Old Pueblo Community Foundation 4501 E. Fifth Street, Tucson Arizona Telephone (520) Fax (520) Oasis House for Women is a structured, transitional & reentry program in Tucson, Arizona, a community venture sponsored by Old Pueblo Community Foundation. Our mission is to provide a clean and sober environment for women in recovery from drug or alcohol addiction, and offer in-house contracted substance abuse counseling. We want to help those individuals who have a desire to stay clean and sober and be productive members of society. We mandate that residents attend 12-step meetings and work with a 12-step sponsor. Membership in these fellowships is important and they may enhance the recovery process of our residents. It is our belief that an honest effort to change lifestyles and deal with personal problems is the first step to long-term recovery. All have to be drug and alcohol free upon intake. Admission Requirements: Must work regular day job - 40 hours per week. Must acquire a 12-step sponsor within14days. Must work our recovery program Must attend substance awareness classes. Must commit for 90 days minimum. Must not have a history of sex crimes. Must be an addict or alcoholic by admission. Must be de-toxed - no methadone. Must be 21 years old No house arrests. We offer semi-private rooms at $90.00 a week. This is a home environment, not an institution. Residents of The Oasis House residents cook for themselves and have access to food in the house if indigent. We provide bedding, telephone, and laundry facilities. Buses stop in front of our facilities making it effortless to ride public transportation. We offer a referral base for job placement, discount bus passes and food stamps. Contract addictions counseling is mandated in-house at The Oasis House. Enclosed with this letter you will find a copy of our house rules and intake form. To apply, write a letter of introduction telling us about yourself and remember that your application will be held up pending this letter. Fill out the application completely; INCLUDE THE NAME AND FAX NUMBER OF YOUR CASEWORKER. Mail application to 4501 E. Fifth Street, Tucson Arizona If you are in the Arizona Department of Corrections we are approved to house TR s, ER s, Work Furlough, and Parole releases. We approve from Pima County Jail. Enclosed with this letter you will find a copy of our house policies and application form. If you have any questions or if we can be of assistance to you, don t hesitate to call. READ THE BACK PAGE! Sincerely, Leah Jones Oasis House for Women (520) x 213

2 The Oasis House Goals and Standards The Oasis House is a supportive group of recovering addicts and alcoholics in a living atmosphere with the primary focus on recovery; learning to live life without the use of mind altering substances. Courtesy, honesty, loyalty, a commitment to care for each other, honoring vigorous standards, service to others, laughter, and sensing God s presence in all areas of our lives are the principles treasured by Oasis House and our staff. Living in The Oasis House is not easy. Only those few who are really seeking recovery will move into our home. Only those seeking a new way of life will make it here. Our mutual success depends upon an attitude of unity and support. We hope that you stay here will be a time of healing, recovery and growth. The changes you make here during your first thirty days are crucial to your sobriety and serenity. You will be asked to change the way you have lived, the way you think, and the people you associate with. You will be asked to change just about everything; attitude, your thinking, your perception of the world, and your behavior! These changes may sometimes be difficult. You will require a great deal of love and support and you will find it at The Oasis House if you want it. The Oasis House is a twelve-step house. The programs of Narcotics Anonymous and Alcoholics Anonymous have proven to be a successful treatment plan for many of us. The therapeutic value of one addict and alcoholic helping another is without parallel. It will work for you if you get a sponsor and work the twelve steps! The twelve step programs require that we diligently work on ourselves. How do we do this? We get a sponsor because we can t do it alone! We learn to build a trusting relationship with another human being who is willing and able to help us. We have to get willing to take direction, write out our steps, read recovery literature, and pray. It works! Honesty, open-mindedness, and willingness are the cornerstones of our program. We need to get honest about our problem, be ready to receive new information, and willing to take action. We didn t get to The Oasis House because we have all the answers. Oasis House is open to all who desire to stop drinking and/or using drugs; membership is limited to those who are willing and able to accept and practice certain spiritual principles. Rigorous honesty with ourselves and others is mandatory. Half measures avail us nothing, as our literature says. We pray that you follow our direction. Recovery is possible for all of us. There are rewards for staying clean and sober. Learning to live a new way of life is attainable, even if you don t believe it yet! Welcome to The Oasis House! Nick Jones, CEO

3 The Oasis House for Women 4501 E. Fifth Street, Tucson Arizona HOUSE POLICIES - LODGING AGREEMENT (7-06 ) The undersigned understands and acknowledges that The Oasis House is an alcohol and drug free shared housing property managed by the Old Pueblo Community Foundation. The undersigned resides in the capacity of a lodger sharing a housing unit and not as a tenant with rights or possession of space exclusively. The undersigned agrees to pay program fees of $90.00 per week and $10.00 per week for substance abuse awareness and education groups and life skills classes. The undersigned lodger agrees to participate in and abide by the policies and rules set by The Oasis House staff. The undersigned agrees to vacate the shared accommodation when cardinal rules are violated or by a vote of The Oasis House staff. The following house policies are to be observed by all residents. These policies have been set forth by The Oasis House to maintain a clean, safe, and healthy living environment for those in recovery and to those who are willing and ready to change lives and transition back into society. Any infraction of these house policies could result in disciplinary action and possible termination from the program. The decision to stay at The Oasis House is based on each resident s behavior, and our goals are to help each resident attain their goal of self-sufficiency by staying clean and sober and finding employment. The Oasis House for Women is a silent address and will never be published in any documentation for the safety of all women residents. All mail will use the Old Pueblo Community Foundation as the return address: the address is 4501 E. Fifth Street, Tucson Arizona Inform all family and friends to put Oasis House in the bottom left corner of envelope. No resident is to give out the address of the facility. No men are allowed on property. Any men seen in vicinity of Oasis House visiting residents will be an automatic termination. Walk out to Walgreen s on Grant and Swan to get rides. THIS AGREEMENT, entered on this day of between The Oasis House and, regarding clean living residency at The Oasis House, includes the following conditions: 1. All program fees are due on your payday, and there is no grace period. If a legitimate emergency occurs, the director shall be informed and may consent to an extension. If a resident moves from the house under emergency circumstances prepaid service fees remaining shall be refunded on a pro-rated basis. Any failure by resident to pay fee s when due, or failure to comply with any other of the conditions of this agreement allows The Oasis House to immediately void this agreement. Any infraction of the house rules may result in the immediate termination of the lodging agreement and expulsion from the house, and forfeiture of any lodging fees for that week. 2. Standard Curfew: All residents who are working will be expected to return to the house by 10:00 pm Sunday - Thursday and 12:00 am Friday & Saturday. One needs specific permission to leave any earlier than 5:00 am. Curfews are designed to help our residents change behaviors and learn new skills. 3. New Arrival Curfew: All new residents will return to the house by 6:00 pm every day. New residents will abide by the Standard Curfew after showing proof of employment. Attaining employment immediately will directly benefit each resident. 4. Medication: The Oasis House does not dispense medication. Our policy prohibits taking mind-altering medications; however, we understand that sometimes we need it. The director, in conjunction with advice from medical professionals, will determine the necessity for prescribed medications. If we feel that a prescribed medication for a resident is detrimental to other residents we will ask that resident to go without, or resident will have the option to move out with full explanation to any supervisory agencies. Any resident sharing or receiving medication will be terminated without question. All medications need to be entered in medication log. (See manager). NO NARCOTIC MEDICATIONS ARE ALLOWED WHILE LIVING IN HOUSE. DO NOT FILL PRESCRIPTIONS. 5. Drug and Alcohol Use: Occupancy is made available on the strict understanding that the house is to be, at all times, drug and alcohol free. Should a resident use any illicit drug, consume alcohol, or take drugs not prescribed by a physician, the resident will be discharged immediately from the house. In addition, guests of visitors of a resident who are under the influence of any type of mind altering substances are not permitted, at any times, in the house or on the grounds. Protecting and/or knowing a fellow resident is drinking or using may cause immediate dismissal. Reporting all suspicions to house manager will benefit every resident 6. House Liability: The Oasis House is not liable for any personal property during or after the resident s discharge from the house. The Oasis House will dispose of all personal property 30 days from discharge date. The Oasis House assumes no responsibility for the personal property of the resident. 7. Payment Plans: Payment plans will be written for all residents that are $ or more in arrears in program fees. They will be written by housing coordinator and client together. Once resident agrees to plan and signs the document, the document will be enforced. All pay stubs are to be shown to housing coordinator. 8. Without permission from Housing coordinator, no resident will: Install paneling, flooring, built in decorations, partitions or railings Drill or attach anything to the floors, walls or ceiling of the house Bring in any dish washing, heating, ventilating, or air conditioning units, or any water filled furniture Put in any shades, blinds, window guards, and in or outside of the premises 9. No loud music. Only Walkman type radios allowed. Loud and excessive noise disturbs other residents and will not be tolerated. The TV s will only be played at reasonable volume levels and violation of these rules will be considered disruptive behavior. Have respect for your neighbor. 10. Visitation: Guests are to be entertained in the living room or patio areas only. All visitations must be taken off property. No guests allowed in the bedrooms and no overnight guests. If any guests cause dissention within the house, that guest will be asked to leave. Visits with sponsors are encouraged. NO CHILDREN ON THE PROPERTY AT ANY TIMES. 11. Intimidation and/or violence. Any open or subtle hints of intimidation or violence towards residents or staff are grounds for immediate termination. No exceptions. 12. No smoking in the house. No exceptions.

4 13. No sexual activity in the house. No exceptions. 14. Housekeeping: Each resident is responsible for washing dishes immediately after eating. Sleeping areas are to be clean at all times. Residents are responsible for cleaning of all community living areas, such as, kitchen, bathroom, living room, den, patios, backyard & grounds, and laundry room. Resident will keep the premises clean at all times, and upon termination will leave the premises in as good condition as when this agreement was entered. All residents are assigned weekly house chores. 16. Community Service: Residents can work off community service at The Oasis House if approved by parole/probation officer. Housing coordinator or house manager will supervise and sign off on all work. 17. Excessive Utilities: Be aware of abusing free utilities. Washers and dryers are available for your use. The Oasis House will pay all water, gas, heat, light, local telephone services, and power to the house. The last person out of each facility each should turn off coolers and heaters. 18. Out of Bounds: Residents may not enter another person s room without permission. 19. No Food Areas: Food will be eaten in the dining and living area only. No food in bedrooms. 20. Passes: Need to fill out pass request form with a minimum of two week s notice. A minimum of thirty days in the house is required. The Director will approve all passes based on performance in the house. All program fees have to be current to be approved. 21. Work: We require all residents to work forty hours a week. All unemployed residents will be dressed and out of the house by 8:00 a.m. and cannot return until 4:00 pm, during the week. The curfew for unemployed residents is 6:00 pm. Residents having trouble with acquiring employment are to ask staff for help. See employment opportunity sheet in your introduction package. 22. Sleeping: All residents must be awake, dressed, areas cleaned by 8:00 am on week days. Residents will not sleep in the living room. Lights should be out by 11:00 p.m. on weeknights. 23. House Activities: All residents will participate in all house activities including business meetings, group sessions, and weekly housekeeping duties. Mandatory work days for all residents maybe assigned for GI duties each month if the house gets filthy. 24. Mandatory House Meeting Attendance: All residents must attend weekly house meetings. This is an important meeting that will cause pain if missed! Don t miss any! No exceptions. 25. Twelve Step Meeting Attendance: All residents must attend 3 outside 12step meetings per week. The meeting attendance slips are to be turned in to the house manager at weekly house meetings. Mandatory meeting schedule is on bulletin board. 26. Sponsorship: All residents will be required to get a 12-step sponsor within 14 days of move in. We will verify with your sponsor. Experience tells us that we can t recover alone. We strongly encourage work with a spiritual sponsor on a regular basis. Read information on sponsorship in intake package. 27. Outpatient Treatment Programs: All residents must attend all court and parole/probation ordered treatment plans, but must work around the mandatory house meetings and in-house counseling. 28. Dress Code: All residents must be properly attired in the community areas. 29. Pornography: No pornography in the house. The Oasis House hopes to offer spiritual living in a spiritual environment. 30. No pets: Residents permitted to have any pets. 31. Telephones: The Oasis House provides free in-house telephone service with voice mail capabilities. Residents are allowed 10 minutes maximum for each call. Violation of this rule will result in consequences. Telephone service is a privilege. Any problems with the telephones and service will be discontinued. 32. Weapons: No weapons of any kind are allowed on The Oasis House property. 33. Notice to vacate: A thirty (30) day notice of intention to move and vacate is requested from all residents. 34. Grievances: If a resident feels that another resident is not doing their share of the chores, or has any other grievances towards another resident, he may call a meeting with the house manager/housing coordinator with all residents to discuss the grievance. If a resident s action or behavior is found unsatisfactory by a majority of the residents at such meeting, the resident will be given the opportunity and reasonable time to change their behavior. If after two meetings the offending resident fails to make the necessary changes the director will be advised, and, subject to his discretion, may terminate the lodging agreement. 35. Sign In/Sign Out: All residents are required to sign out when leaving premises, and sign in upon returning. 36. No parking in front of house: All residents will park cars in the back of the facility. All visitors and pickups will park in back. No exceptions. 37. Consequences: The staff of The Oasis House reserves the right to enforce the following consequences for infractions of any, or all, of the above house policies. The consequences may include extra chores, restriction to the house, no passes, or termination. 38. Vehicles: To operate and/or park a motor vehicle while residing at the facility, a valid driver s license, proof of insurance and registration are required. Copies need to be in file at the main office and house manager s office. No non-running vehicles are allowed to be parked on any of the residential facilities. They will be towed at your expense. If you own a vehicle and can t legally drive it, park it elsewhere. Please print the following: I HAVE READ AND UNDERSTAND HOUSE POLICIES AND LODGING AGREEMENT Residential Information Concerning Applicant/Resident May Be Shared With Appropriate Agencies (Sign Here) Signature of Lodger: Printed Name of Lodger: Signature of House Manager: Dated: Dated: Dated:

5 Casa Santa Clara/Oasis House Resident Application (Revised 7-06) You are required to write a brief bio letter with this application. We want to know who you are, where you came from, and where you want to go in life. Letter is required to process application. If you have trouble writing, let us know. FILL IN ALL THE BLANKS OR YOUR APPLICATION WILL NOT BE CONSIDERED. THANK YOU. Name: Case/DOC#/: Today s Date: Date of Birth: Age: SS#: Circle One: Single Married Divorced Separated Identification: (Circle) Driver s License AZ ID Card DD-214 SS Card Birth Certificate Tribal Other: Current Contact Phone Gender: Male Female Are you pregnant YES NO Veteran YES NO How did you hear about our program? Are you receiving county, state, or federal benefits? YES NO What? Why? Have you ever received county, state, or federal benefits? YES NO What? Why? Current Living Situation (Circle One) Streets Shelter Detox Jail/Prison Rental Housing Transitional Living Hospital DV Shelter Family Other Name of current contact: Current address? CAN YOU PASS A DRUG TEST TODAY? YES NO What is your drug of choice? Name types of drugs and alcohol you take: Date Last Used and/or Drank: Frequency of Use: Type of Drug Intake: (circle one) Snort IV User Smoke Oral Are you willing to detox? YES NO What is your history of alcohol and substance abuse? Currently Employed? YES NO If no, last place of employment Date last worked: Name, address and phone of current employer Pay Rate: Type of Employment Current Income: Date Last Worked Who can we call to verify application (Circle One) PO Public Defender Attorney Case Manager COIII Pretrial Other Name Fax (Required) ( ) Phone # ( ) If incarcerated, we need a contact name above. If you don t know, find out. Application forms require a contact person to process Do you have current charges? YES NO If yes, what? If yes, next court date: Are you a Parole Violator? YES NO Reason for Violation: Anticipated Release Date: Are you on supervision (Circle One) IPS Direct Regular Parole Fed Probation No Supervision Agency: PO Name Phone: Office Location Do you have court fines? YES NO How much? Do you have community service? YES NO How Many Hours? Are you under physician s care? YES NO If yes, why? Dr. Name: Phone: Agency: List all physical medical problems: List all past and current psychiatric encounters: Are you under the care of a behavior health facility: YES NO Agency Name How long?: Are you prescribed psychotropic meds? YES NO Do you possess meds? YES NO Medications Prescribed: Will your doctor prepare a work release letter? YES NO Have you every attempted suicide? YES NO If yes, explain Caseworker/Doctor Name: Phone: Diagnosis: Are you willing (YES NO) and capable (YES NO) of working 40 hours a week of gainful employment during the day shift immediately?

6 Have you ever been arrested for any sex crimes? YES NO If yes, Explain: Did you read the lodging agreement and house policies? YES NO Are you clear on what is expected of you? YES NO Why do you want to come to Casa Santa Clara? What is your occupation? Do you have any job prospects?: YES NO What are they? Are you interested in employability training? YES NO What are your job interests? Have you ever attended 12 step meetings? YES NO How long? Are you willing to attend three 12 step meetings a week? YES NO Are you willing to work with a 12-step sponsor each week? YES NO Attempts to get clean and sober Most clean/sober time attained List all arrests, convictions, sentences, prior prison or jail commitments, and probation history? (list places and dates use blank paper if needed) List names and dates of all treatment programs, outpatient programs, and halfway houses attended. (Be specific) Highest Grade Completed Education Completed (Circle One) High School GED Vocational School Junior College University School or other formal training from age 14 (e.g. high school, technical school, apprenticeships, on-the-job training, computer, etc) Name and Place From (Year) To (Year) Certificates, Diplomas Obtained Type or Main Subject Are you in the process of family reunification with family? YES NO Explain: Do you have Children?: Ages: Sex: Are you paying child support? What are your goals in life? Where did you grow up? Do you have financial support for fees? YES NO INFORMATION CONCERNING APPLICANT/RESIDENT MAY BE SHARED WITH SUPERVISING AGENCIES (Sign here) All information on this application is true to the best of my ability: (Sign Here) In case of emergency notify: Forward Mail to: Name Relationship Phone ( ) Address City State Client Name (Print) Client Signature Date DO NOT WRITE BELOW Go to next page FOR OFFICE USE Interviewer: Attitude: Location Assigned: SHP Program: Date Interviewed: Date Accepted: Date Entered: Date Exited: Denied? Why Agency Referred By: Caseworker: Acceptance Letter Faxed to Caseworker? Date: Acceptance Letter Mailed to Applicant? Date: Financial Status: Funds Arranged? YES NO By Whom: Phone: Re-Admit? Left Owing (Program Fees) $ (Counseling): $ Status of Last Stay Homeless Status: Homeless YES NO Chronic YES NO What are clients immediate needs?: If assigned to a SHP Program, why? Comments: