Fill - Free fillable Hope House McAlester %28women%29 Application Hope McAlester (women) application.pdf PDF form

the

Hope

House

Program

What

i.~·

!he

Hope

House

Program?

The

Hope

H()Use

Program

is

designed

to

help

women

that

arc struggling with life-controlling

probleJ?S·

We

arc a

faith-based

program

designed

to

help

women

realize that

we

can

achieve

success

in

all

areas

of

life.

For

l

know

thr!

plcms

I hctvefor

you,

declares

the

Lord,

plans for a

hopa

and

a

future

Jeremiah

29:11

Mission Statement

Vision

To

extend

the

hand

of

hope

to those

in

need

of spiritual

and

physical

help.

Mission

To

provide

a

Christ-focused,

nurturing

environment

to

empower

women

and

their

children

to

become

productive.,

self-sufficient,

contributing

members

of their

society.

Objectives

To

create

a

positive,

spiritual

environmetlt

where

women

feel

safe,

secure

artd

have

all

their

basic

needs

mel.

To

have

a staff that

is

committed

to

going

the

extra

mile

in

order

to

help

women

bring

about

a lifestyle

change

in

their

rt!covery

process.

To

enable

women

to

become

spiritually

alive,

emotionally

stable,

physically

healthy

and

socially

active

in

all

aspects

of

society.

Office Procedures

Administration

...

the

Key

to

Successful

Outcomes

Intake Procedures

Otice

a person

has

decided

to

~;om~

into

Hope

House,

intake procedures can

begin.

Intake

staff

will

ask

the applicant

the

questions

on

the

Intake

Application.

The

intake

process

involves going

over

the

program

with applicant, assisting

with

filling out the

appllcation>

explaining

the

program's mission statement

and

rules,

and

making

sure the applicants

understanJ

Lheir

commitment.

Intake

staff

must

obtain

as

much

infonnation

as

possible

from

the

applicant

to

better

evaluate

the

potential

client's

~ituation.

Upon

completion

of

paperwork,

the

new

client

wiH

them

be given

the

opportunity

to

rnake

a l 0

minute

phone

cal!

if

necessary,

to

inform

lnends

or

relatives

of

whereabouts.

New

client

will

then

begin

Hope

H()use

process.

This

involves a

thorough

search of

all

personal

belongings

by

Hope

House

staff.

All

bags

will

be

emptied

out

and

inspected;

individuals

will

also

empty

out

~ntire

contents of

the

it·

clothing

to

be

searched

by

Hope

House

staff.

Qualifications

Are

you willing

to

commit

to

Hope

House

program?

L Commitment

to

the

Hope

House

program

requires that

you

follow

all

rules

of

Hope

House.

2.

Are

you

willing

learn

Godly

habits?

Yotl

are

required

to

attend

all

in

house

ministry

gronps

&

required

to

go

to

chUI·ch

every

Sunday

unJ

Wednesday

3.

Do

you

have

any

pending

legal

matters?

Hope

House

Program

is

not

a

residential

care

facility;

therefore

uuy

legal matters that

may

need

to

be

taken care

of

must

be

dealt

with

by the client

and

at

their

own

expense.

If

you

are

on

probation

or

parole you must

have

a letter

from

you

probation

or

parole

officer stating the

conditions

of probation or parole

npon

entry

into

program.

4.

Do

you

have

any

medical

conditions (including pregnancy

anc.l

HIV)

pending or present?

Hope

House

is not a

residential

cure

facility

and

therefore,

any

medical

conditions

that

may

neec.l

to

be

taken care

of,

rnust

be

dealt with

by

the client at their own

expense.

You

must be medically

and

physically able to perform volunteer

work

assignments

as

part

of

the

program.

You

cmmot

have

been

diagnosed

with

any

chronic illness,

which

would

prevent

you

from

pc1forming

your volunteer

work

assignments

as

patt o!'ihe

Hope

House

Program_

S.

Have

you ever been

diagnosed

with

any

mental

illnest>es

within

the

last

year?

Hope

House progtam

is

neither

a

menta1

health facility

nor

a

hospice.

For

this

reason

Hope

House

n1ay

not accept

someone

into

the

program

that

is

not

being

treated for

mental

illnesses.

The Hope House

program

is a faith-based

pl'Ogram

aimed

at

establishing a

person

in

Christ

so

the

individual

cao

live

a successful life. During

the

course

of

a

stay

the

client

will

bave

performed

community service

to

our

local

neighborhoods

as

well as

participating

in

numerous

studies

and

classes, which include

but

not

limited

to

Angel'

Management, Character training

and

Goal Achievement.

In

nddition

to

this

we

may

also

use

various faith-based curriculums.

• The Program Coordinator

will

provide

support

to

the Executive Director, Shelter

Managers>

Residential Advisors and Volunteers.

•

The

Program

Coordin(l.tor

will

be

responsible

tor

perlbnning

the

following

dnties:

Shelter

Manager

o Maintain records

of

all

necessary

updates

relevant

to

clier'lts'

progress.

o Assist

in

conducting intakes into the

program.

o Keeping confidential records maintained

and

secure.

o Keeping

up

the

database

up

to

date

and

current.

o

Facilitate a constant communication

flow

between the Executive

Director's

o1lice

and

the

appropdate starr involved in

the

day

to

day

operation

of

the Ilope House.

o Ensure that the Executive Director

is

kept

cunent

on

all

relevant

data concerning the

progress

of

the individual clients.

o Coordinate activities

\Vith

other ministries or

programs

with

regards

to

the

need.c:

of

Hope

House.

o Coordinate

schedule

o

Mai11tain

adequate inventories

of

all

promottoJ1al

materials of

the

Hope House.

o Maintain a positive, life-giving environment

for

the

clients

and

staff.

o Perform other duties

as

needed to maintain the operation

of

the

Hope

Honse.

o

Use

language that

is

respectful, practice confidentiality,

and

provide services

to

the

best

of

their ability witllout prejudice.

•

The

Shelter Manager is

required

to

answer to the Executive Director

•

The Shelter Manager

will

present

and

uphold

all the Hope House policies

and

procedures

as

m1tlined

in the Policies and Procedures Manual.

•

The

Shelier Manager will provide

s~tpport

to

the

Exectttive Director,

Program

Cootdinator,

Res1dentia1

Advisors

ulld

Volunteers.

•

The Shelter Manager

will

be

responsible

for

performing all the

following

duties:

o Provide overall direction

to

clients.

o A vailablc

to

answer

phone calls regarding clients

progress.

o Maintain schedules relevant

to

respective clients

..

o Monitor overall progress

of

client~.

o Maintain

up~to-date

records

and

progress reports

on

each

client.

o Assist clients with

Probation

and

Parole requirements and provide

those entities with progress

rcpo11s

and

suppot1ive

documenlation

about

the

progtam.

o Keep Executive Direelor

and

Program Coordinator updated

on

clients'

progress.

o Provide

en~ouragemenllo

clienls.

Areas

of Responsibility

If

you

don't

know

where

you're

going

...

how

will

you

know when you get there?

Executive Director-

Tina

Adams

The

Executive

Director

is a paid staffperson that

has

been

selected

to

oversee

all

aspectt>

of

the

Hope

House

program.

Some

of these

duties

are

outlined

below

• The

Executive

Director

is responsible for

all

aspects

of

the Hope

House

program

•

The

Exec~ttive

Director

is

required

to

answer

to

the

Board ofDin:ctors

•

The

Executive

Director

will present

and

uphold

all

the

Hope

House

policies

and

procedures

as

outlined

in

the

Hope

House

Policies

and

Procedures

Manual

• The

Executive

Director will provide support

to

the Program

Cootdinator)

Shelter

Martagers~

advisor,

volunteer:),

and

Hope

House

managers.

•

The

Executive

Director

wllt

be

responsible

for

performing

the

followhig

dutie~:

o

Oversight

ofthe

Hope

House

in its

entirety.

o

Responsible

for

compiling

a

report

to

the

Board

of Director's

meetings.

o Supervising Coordinators

and

Managers.

o Cultivate

and

maintain

good

working

relat1om;h1ps

between

Hope

House

artd

other

ministries

so

as

to

p:roruote

an

attitude

of

team

work

and

Chdst-like

compassion.

o

Ensure

a constant

flow

of

communication

to

the

coordinators'

and

managers

in

order

to

help

them

in

the

day

to

day

activities of

the

Ilope

House.

o

Maintain

adequate

recotds

of

residential statistics.

o

Provide

oversight

ror

M~mager::;

in spiritual

counseling

to

clients.

o

Maintain

a

positive,

life~

giving

environment

for

the

clients

and

staff

perform

other

duties

as

needed

to

maintain

the

operation

of

the

Hope

House.

o

Usc

language

that

is

respectfi1l,

practice

cont1dcntiality,

and

provide

services

to

the

best

or

the

ability

and

withont

prejudice.

Program

Coordinator

The

Program

Coordinator is a

volunteer

or

a

paid

.starr

person

that

has

been

selected

to

assist

the

Execulive

Director

in

her

duties

of

administrating,

maintaining,

and

communicating

of

the

overall

strntegies

orthe

Hope

House

Program

to

the

Board

of

Directors

and

the

Hope

House

stuff.

Some

of

these

duties

ure

outlines

below.

•

The

Program

Coordinator

is

required

to

answer

to

the

Executive

Director.

• The

Program

Coordinator

will

ptesent

and

uphold

all

the

Hope

House

policies

and

procednres

as

outlirted

in

the

Hope

HQuse

Policies

artd

Procedures

Manual.

Residential

Advisors

o

Work

closely

and

cooperatively

with

other

Hope

House

staff.

o

Maintain

a positive,

life-giving

environment

for

the

clients

and

staff.

o

Perform

other

duties

as

needed

to

maintain

the

operation

of

the

Hope

House.

o

Use

language

that is

respectful,

practice confidentiality,

and

services

t~i

the best of

their

ability

and

without

prejudice.

The

Residential

Advisor

is

a

volunteer

or client that

has

been

selected

to

monitor

and

supervise

the

clients that

are

in

their

hallway

on

the day-to-day activities of

the

Hope

House.

•

The

Residential

Advisors

are

required

to

answer

to

the

Executive

Director

•

The

Residential

Advisors are

to

support

and

uphold

all

the

Hopt!

House

policies

and

procedures

as

outlined

in

the

Policies

and

Procedures

Manual

•

The

Residential

Adv1~0r$

will

provide

s~1pporl

to

the

Executive

Director,

Program

Coordinator,

and

Shelter

Management

•

The

Residential

Advisors

will

be

responsible

for

maintaining

the

following

duties:

o

Advise

client-;

concerning

rules

and

curriculum.

o

Be

an

encouragement

to

clients.

o

Have

daily

ilme

of

prayer

with

all

clients

in

their care.

o

AM

duties are

to

wuke

up

and

advise

the

clients

of their

morning

and

afternoon activities.

o

Make sure all clients'

rooms

arc

clean

and

in

order

o Report all necessary maintenance

repairs

to appropriate

persona\_

o

Complete

minor

repairs_,

i.e.,

change

light

bulbs,

etc.

o

PM

duties

are

to

advise

the

clients

conceming

their

afternoon

and

evening activities.

o

Advise

the

clients

on

their

floor

about

the

benefits of getting a

good's night's

sleep

and

make

sure lights

are

out at the

appropriate

time.

o

As

necessary,

fill

out

incident

reports

and

place in the Shelter

Managers

mai1box.

o

Relay

to

the

Sheher

Manager

of

any

indication

of

possible

problems that

the

client

may

be

going

through.

o

Complete

Daily

Repotts

and

tum

in

DAILY

to

the

Shelter

Manager.

o Maintain a positive,

fife-giving

environment

for

the

clients

and

staff.

o

Perform

other

duties

as

needed

to

n1ah1taiil

the

operation of

the

IIope

House.

o

Use

language that

is

respectful,

practice

c;o11fidentia\ity,

and

services

to

the best of their ability

and

without prejudice.

Schedule

Jj

You

Pail

to

Plan

then

you

w·r;

planning

to

fail

Having a schedule

is

an

effective

way

to

bring order

into

a person's

life.

Not

only

is

it

impo11ant

to

have

a

schedule

but

it

is

equally impol1ant

to

adhere

to

that schedule. A

schedule

also

provides a

tool

to

monitor

a person's progress by how

well

they

adhere

to

that

schedule.

The

following

is schedule that

we

have

all

clients

adhere

to.

Each client

is

required

to

be

at

each

scheduled event at the

designated

time. Schedules will

be

posted outside the office on a

weekly

basis.

Example:

Monday

~Tuesday

Wednesday

Thursday

Friday

8:00-8:45 Nutrition

9:00-10:00 Fitness

10:00-12:00 Housjng/ Job Search

12:00-1

:00

Lunch

1:00-5:00

Work

Therapy

5:00

Dinner

1:00

Church

9:00-4:00

Work

Therapy

4:00-5:30 Dinner

5:30-6:30 Parenting

7:00

Church

9:00-10:00 Fitness

10:00-5:00

Work

Therapy

5:00

Dinner

7:00

Church

9:00-12:00 Counseling/

Work

Therapy

1:00-5:00

Job

Search/ Work Therapy

5:00 Dinner

7:00-8:00

Church

9:00-10:00

Fitness

10:00-5:00

Work

Therapy

House

Rules

As

for

me

cmd

my

house ...

we

will serve the Lord!

Hope

House

is

a

program

that

is

based

on

choices.

The

choices that

we

make

determine

not

only

where

we

are

headed

but

also

where

we

have

been.

Poor

choices

arc

sometimes

the

result

of

not

following

boundaries

that

have

been

established

in

our

society.

The

rules

for

Hope

House

have

been

established

to

help

you

reestablish

and

maintain

bo~mdaties

in

your

life.

These

rules

have

been

carefully

and

prayerfully

thought

out

and

have

been

put

in

pl<tce

to

help

you

in

your

j

ourncy

towards

a

successful

life.

1.

Admission

•

Admission

into

Hope

House

is

a privilege

and

nol a

right.

•

Upon

admission,

the

client

must

submit all

possessious

and

person

to

inspection.

•

An

inspection

may

be

conducted

at

any

time

that

there

is

a

reasonable

c~use

to

suspect

that

contraband,

dtugs,

and

Ol'

drug

paraphernalia

may

be

present

either on

the

person

or

in

the

rooms

assigned

to

that

person.

•

All

clients

will

be

supervised

by

staff

and/or

Residential

Advisor::>

during their

stay

In

IIope

House.

All

requests

and

problems

will

be

channeled

lhnmgh

the

Staff on

duty.

All

requests

must

be

written,

signed

dated

and

given

to

the

!:>t~ff

on

duty.

2. Spiritual Life

•

Hope

House

Is

a

Faith-Based

progrrun.

As

such,

there

is

a

spiritual

component

required.

•

Thi~

includes

but

not

limited

to;

Church

services,

bible

studies,

prayer

services

and

public

services

that

are

essential

to

the

program.

•

All

clients are

required

to

attend

such services

or

classes.

NO

EXCEPTIONS!

•

There

will

be

no

talking,

reading,

writing

letters,

talking

on

the

phone using

the

restroom,

or

getling

a

drink

during

any

bible

study,

prayer

meeting,

Church,

group

or

any

other

activity.

3. Privacy

•

Since

Hope

House

is

a residential live-in program

with

many

clients,

there

should

be

no

expectation

of

privacy.

•

Hope

House

reserves

the

right

to

perfonn

room

searches

when

deemed

necessary

by

the

Executive

Director,

Program

Coordinator

or

Shelter

Managers.

•

Hope

House

also

reserves the

right

to

use

closed

circuit

TV

in

hallways

and

entrances

for

seculily

purposes.

•

No

Client

can

lake

pictures of another client

and

post

in

on

a

website

(Facebook,

MySpnce)

or

have

it

developed.

4.

Probationary

Period

•

The

staff will

observe

the

client

and

decide

if

she

meets

the

requirements

to

continue

in

the

program.

Growth

•

During

the

client's

stay

here at

Hope

House,

the

client

will

be

required

to

show

progressive

growth.

• "Gtowth"

constitutes

participation

ill

work

assignments,

classes,

Bible

studies,

prayer,

Bible

reading,

room

cleanliness,

personal

hygiene,

morning

devotion,

church

services,

and

any

other

required

activity

by

Hope

House.

•

Growth

is

also

mea.,mred

in

terr11s

or

the

development

of

character,

integrity,

and

relationships

with

sisters

in

Christ.

•

Failure

to

produce

such

growth

constitutes

grounds

for

dismissal.

6.

Family Visits

•

Family

visits

are

allowed

in

accordance

with

Hope

House

privileges

and

restrictions

guidelines.

•

Hours

or

vhdt(l.tion

are

on

Sunday

from

11:30

to

4:00.

•

No

girlfritmds,

boyfriends, Ol'

fiances

shall

be

permitted

to

visit

on

Family

Day

unl~ss

there

are

children

involved.

•

Family

visits

arc

not

allowed if

you

are

on

discipline.

•

All

family

visits

must

be

pre-approved

prior

to

taking

plac.:~,

NO

EXCEPTIONS!

7.

Drugs

•

You

are

not

allowed

to

have

any

of the

following

items

in

your

possession

or

in

your

room;

alcohol,

any

illegal

substance

and/or

paraphemalia

us

well

as

unapproved

prescription medication,

over

the counter

medication,

or

n1edk:ation

that

is

not

prescribed

to

you.

•

This

also

inclndes

co11tact

or

association

with

individuals

under

the

inl1uence

of,

or

possession

of,

the

previously

mentioned

drugs.

•

While

in

the

progrrun

you

will

be

required

to

submit

to

random

drug tests

and

room

searches.

• A positive

drug

test

may

be

grounds

for

inuuediute

discharge

from

Rope

House.

•

Those

with

a

substance

or alcohol

abuse

problem

will

be

refened

to

the

appropriate

agency.

There will

be

no

sharing

or

abusing

prescriptions.

•

Anyone

with

any

drug

or

alc(lhol

abuse

is~ues

will

need

to

take

al1east JN/ A

or

AlA

meetings

a

week

and

to

attend

a

church

of

your

choice

once

a

week.

8.

Violence

•

Violence,

abuse

or

threats

of

violence

or

abu~e

ure

not

allowed

at

any

time.

•

This

includes

swearing>

threats,

namc~calling

or

threatening

tone

or

level

of

voice

toward staff or other dicnts.

•

Horseplay

will

not

be

allowed

as

this

can

lead

to

aggressive behavior.

9.

Weapons

•

No

weapons

of

any

kind

will

be

aU

owed

during

the

duration of

the

program.

• This includes firearms,

knives,

or

any

l)ther

object that

may

be

used

u~

a

weapon.

10. Relationships

• There

is

to

be

no

fratemizat1on

between

two

individuals

inside

or

outside

for

the

purpose

of

establishing a romantic relationship.

Tlus

include~

flirting,

dating, inappropriate conversations

with

members

of

the opposite sex or

same

sex,

or

sex

in

any

form.

•

This

includes other clients

attd

R.A..'s

as

well

as

any

other

person

that is

in

Hope

House.

11.

Illegal Activity

• Illegal Activity

will

not be tolerated. This includes

any

activity or behavior

not covered

above

lhul

would

be considered illegal in a society.

12.

Mail

• Letters are

to

be

written.

during

free

time

only so

as

not

to

interfere

with

study

or

work

time.

•

Hope

Home does

reserve

the right

to

inspe<..'t

and censot

all

incoming

mail and

packages

as

they

arc

being

opened by

the

addressee lbr security purposes.

•

Hope

House,

at staff discretion, restricts a client

from

communicating by

mail

with a specified indjvidual or individuals at the request of

stan:

lan1ily

members,

or

close

friends.

•

ClienU!

are

encouraged

to

write their

spouse,

children,

purents

or

other persons

designated

as

"FA.MILY"

on

a regular basis.

13. Telephone Calls

•

Upon

entering the

program

the

client is

allowed

one

10

minute

phone

call

on

the

phone

within

the

first

72

hours.

• Office telephones

are

for

staff

only.

·

•

All

telephone calls

on

the

phone

are

limited

to

10

minutes.

• Clients

are

not

allowed

to

um;wer

incoming

calls, but messages will be

takett

and

the client

may

return

call

during their next scheduled

time

unless

it

is

an

emergency.

•

An

M1ergent:y

is

dellned

as

death,

u life-threatening circunistance

or

serious

illness in

the

f'ami1y,

etc.,

and

shuH

be

detennined

by

stall

• Anyone caught

using

the

phone

without authorization

wiU

be

disciplined

accordingly.

14. Medical

Care

• Each Client is

responsible

for

their

own

transportation

and

medical

bills that

they

incur. Therefore,

Hope

House

cannot

be

held

responsible

for

these bills.

•

lt

is

the responsibility

of

the

client

to

infom1

slal1'

of

any

chronic

medical

problems

upon

enlry

into

Hope

Hou:se.

• Prescription

and

over

the

counter medications

wlU

be

locked

up.

1S.Food

•

Food

i~

allowed

to

be

eaten only in designated

areas.

•

No

food

is

allowed in your rooms.

• Kitchen is closed

at

8:30p.m.

• You

are

responsible

lbr

making

your

own

breukfast

and

lunch.

This includes

cleaning

up

after yourself,

by

washing, drying, and putting

up

your

dishes and

wiping down

stove,

cabinets and table,

and

sweeping

up

anything that

muy

have

fullen on the

floor.

• Dinnet

nm~t

be

started at 4:00p.m.

and

c.lone

by

5:30p.m.

•

The kitchen

will

be

open at 6:30a.m.

to

8:30p.m.

All

cooking

and

eating

at

this time.

16. Persona] Finances

• Hope House

is

not

responsible for

any

lost or stolen valuables.

• Panhandling

or borrowing

money

from

anyone

is

not allowed.

•

Discussion

of one's

personal

financial

ability

or

lack.

then~ofwill

not

be

tolerated.

•

No

seiling anything

to

other clients.

•

N0

selHng

your

Food

Stamps.

(Jfs

Illegal)

17. Dl'ess Code

• Clients

are

only

to

have

clothing that

will

fit

in

their space.

•

No

Tank tops, spaghetti string

tops,

halter tops or bare midriff

lops.

• Clothing must

be

modest,

not reveling,

not

low-cut

and

nottight fitting.

•

Due

to the

many

tours that

we

have here at Hope

House

you

must

be

fuHy

dressed

when

not

in

your

room.

• Dress must

be

modest

18.

Laundry

•

Laundry

will

be

done

on

a weekly

basis.

•

All

bedding

will

be

washed every

weekend.

•

AH

residenls

will

have

u

de::;ignaied

lime

that

they

will

be

able

to

do

their

la~tndry.

19.

Rooms

•

Rooms

must

be kept neat

and

organized

at

aU

times.

• Everyone's

room

must

be

clean by

8:00a.m.

NO

EXCEPTIONS.

•

Furniture

wilt

not

be

moved

from

room

to

room

without

permission

from

Executive

Director.

•

No

candles

or

incense

bum1ng

is allowed

in

the

rooms.

•

Personal

possessions

must fit in the allotted storage space.

•

Coffee

pots, hot plates, toaster ovens,

microwaves,

etc.,

are

not

allowed

in

individuals

rooms.

•

Any

hook:)

mu:;t

!l.t

in

drawerH

or

in

a

hook::;nel~

if available

•

Only

1uggagc,

shoes

and

laundry

bags

are

allowed

under

your

bed.

•

Yotl

are

not

allowed

in

another

person>s

room

or

floor

without

penni::;sion

frOiil

staff.

If you desire fellowship with

another

you

may

use

living

areas.

• Quiet time

begins

at

9:30pm

and

ends

at

wake-up

call

the

20.

Hygiene

•

All

clients

must

maintain

personal

hygiene

habits

on

a daily

basis.

This

includes

but

not limited

to

taking a

shower,

brushing

t~eth,

wearing

deodorant

•

Tfyw

n~ed

S~lpplies

lor

any

of

these,

please

Iet

Hope

House

staff

know

•

Hope

House

staff

will

provide generic

hygiene

supplies

until

you

have

a job

and

can

provide

those

for

yourself.

If

you

have

any

special

requirements

or

brand

preferences

it

is

up

to

the client

to

provide

these items

at

their

own

expense.

21. Accountability

•

You

cannot

leave

property at any

time

without permission

from

staff

on

duty.

• Curfew

to

return

to the shelter

for

women and children

is

8:00p.m. each

evening. Except

on

Saturday:

Cm·few

wiJI

be untillO:OOp.m.

All

residents

staying out past

curfew

couJd

be

nsked

to

leave, unless

it

is

a requirement

of

yomjob

and

cleared

through the Executive Director.

It

will

be

asstuned,

if

you

have

a place

to

stay overnight,

you

no

longer

need

our

services.

22.

Work Therapy

•

You

arc expected to

do

your

assigned

work

therapy al

the

des1grtated

times.

•

Any

questionB

regarding

work

lherapy

should be

directed

toward

staff.

•

If

you

are

ill

(fever,

vomiting or other

acute

illnesses),

you

will

remain

on

bed

rest all

day.

•

Not

feeling

like

going

to

work

or

being

too

tired

is

not

an

acceptable

excuse

tor

not

working.

•

No

client

is

to

be

ln their

rootn

during

their

work

therapy

time

without

pennission

from

staff.

23. Classes

•

Clients

must

be

on

time

for

all

classes.

24

Language

•

In

order

to

strengthen

and

encourage

one

another,

all

street

talk,

cursing,

backbiting,

gossiping, jail

talk,

and

sharing

of

past

experiences

among

clients,

that

is

not

positive

in

nature,

is

to

be

stopped

upon

admission

into

the

program.

• lt

is

also

unacceptable

to

speak

in

a

derogatory

manner:

townn.ls

other

clients,

staff

or

any

other

person.

25

Pea·sonal

Possessions

•

Each

client

is

allowed

to

bring

some

uf

lwr

personal

possessions.

Certain

items

arc

not

allowed

at

the

facility.

•

Any

prohibited items

will

be

confiscated

and

disposed

of.

•

All

appliances

must

be

turned

off

when

not

in

use.

•

No

phone

use

during

any

Hope

House

activity.

•

Personal

music

devices

arc

a!lowcd

including:

CD

players,

cassette

players,

I-

PODS,

etc.,

However,

aU

usage

of

personal

music

devices

should

be

considered

a privilege,

and

can

be

taken

away

if

the

client

i~

abnsing

the

privilege.

• Clients are not

allowed

to

use

another

person's

items.

•

Clients

arc

not

allowed

to

lend

or

borrow

n1oney

from

each

other~

staff or

volunteers.

•

Cli~nts

are not

allowed

to

exchange

or

sell personat

items,

belongings

or

services

to

each

other.

•

No

pets

arc

allowed

inside

of

Hope

House_

•

Absolutely

No

ringtones

on

your

phone

with

cuss

words

or

sexual

innuendoes.

26

Pornography

• Possession

of

or

viewing

pornographic

material in

any

form

wiU

not

be

allowed.

27. General Etiquette Rule

•

All

clienls

will

observe

and

maintain

the

utmost

cou1tesy

and

matmers

dernonstrating Chdst-like character

and

attitude

towards

others.

'

We

lb1low

the

Golden

Rule;

"Do

unto

others

as

you

would

have

them

do

\mto

you."

28.

Probation

and

Parole

•

All

clients

wi!f be expected

to

cooperate with ulllaw enforcement

agencies.

•

Any

client

who

has

a court

appearance,

probation

or

parole

n1eeting,

or

legal

appointment

must

set

up

a meeting

with

the

Executive

Director.

•

You

will

be

required

to

provide

proof that

you

ure

to

appear

and

shall

provide

your

own

transportation

and

the

money

for

the

trip

to

and

from

the

destination

if

out

of

Pittsburg

County.

•

No

side

trips

allowed,

you

must

go

to

your

appointment

and

straight

back.

29. Community Service Tickets

•

Community

Service

Tickets are the

mode

of

discipline

we

use

at

Hop!:!

Hm.tse.

•

When

presented

with a ticket, you

must

sign

the

ticket

to

acknowledge

receipt

of

the

ticket.

•

If

you

feel

you received

the

ticket unjustly,

you

may

file

a

gl.ievance

form

in

the

office.

Failure

to

sign

a

t1cket

will

result

in

more

discipline,

up

to

and

including

a

demotion

or

dismissal.

•

A

community

service ticket is

issued

upon

observance

or

a violation

of

the

posted

nlles.

•

The

client

is

Iequired

to

complete

the

appropdatc

number

of

hours

required

for the violation

during

the designated

Limes.

•

All

privileges

are

suspended while a client

has

conununity service

hours

pending.

30. Dismissal

• l fan

in.dividualleave::;

or

is

dismissed

from

the

program

it is

mandatory

that

they

take

ali

of

their

clothing and personal possessions with

them.

•

Hope

House

shall not

be

responsible

for

any

clothing

or

personal

possessions

left

behind

by

the client.

• You

must

tum in

any

sheets,

towels

or

issued

clothing

upon

departure.

•

If

dismisse<l

from

the

program

you

may

noltetum for a

minimum

of

30

days.

• If distnissed,

you

are not allowed contact with

anyone

in

the

program

without

approval

Jrom

ihe

~helter

Manager

or

Executive Director.

30.

Grievances

•

If

ther~

is

a

problem

with

anothet client

you

must first

try

solving

it

with

them.

• lfthc

problem

cannot

be

taken

care

of client

to

client then

ask

the staff

on

duty

to

help

yo\\

resolve the

problen1.

• Clients

have

the

right

to

Cile

a

grievance

with

the

Executive

Dire(.ltor

(must be

in

writing.)

•

Clients

may

have

a direct

access

to

the

Executive

Direetor

ai

some point

in

the

grievance

process,

if

necessary.

•

Grievances

will be resolved

in

a timely

fashion,

usually

within 7

days.

31. Schedules

•

You

are

responsible to

know

and

comply

with

your

posted

daily schedule.

•

You

are

required

to

attend

all

functions

of

Hope

House

and

be

on

time.

• Any changes to schedule

will

be

communicuted

aller the morning devotions

or

through

staff.

•

Curfew

is

8:00p.-m.

Sunday

thru

Friday

and

10:00

p.m.

on

Suturday.

•

All

residents must be

up

by

7:00a.m.

Each

morning

to

address cunent

needs,

unless

there

are

extenuating citcumstances

,(lttch

as

an

illness or other

circumstances

approved

by

the

director.

Tf

you

or

your

child

is

ill

please

confine

yourselves to your

room

so

we

don't

rll3k

an

outbreak.

IT

IS

YOUR

RESPONSIBILITY

TO

GET

YOUR SELF

UP

AT

THIS

TIME!

•

The

televi~ion

will

be tumed off

no

later

than

lO:OOp.m.on

weeknight

may

be

left

on

later at

the

discretion of

the

Shelter

Manager

on

weekends.

•

No

sleeping during the

day

unless

you

have

worked a graveyard shift

and

is

approved

by staff.

32.

Children

•

After

admission to

Hope

House,

residents

have

3

days

to

get their

child

or

children

enrolled in school

No

Exceptions!

• Stafr

must

approve

all

babysitting

and

babysitting

fotml3

must be filled

out.

• Children are

to

be

supervised

at

all

times!

both inside

llitd

outside

of

the

shelter.

A parent must

accompany

their small child/children to the

bathroom,

if

needed

or anywhere there

is

potential

for

hanu

which

includes the

playtoom.

If

you

are

unable or unwilling

to

supervise your

c1lildlchildrcn

you

will

be

al3ked

to

leave.

•

No

disciplining other children by yelling

or

physical abuse.

•

No

Soiled

or Wet Diapers will

be

Left

in

the

Rooms

at

Any

Time!

All

diapers

must

be

taken outside

to

the

trash

bin

inm1ediate\y.

•

Residents

working or seeking

employment

are

responsible

for

providing

daycate

services for their child/children.

Hope

House

does

not

provide

daycare.

Childret1

left unattended

may

be

reported

to

Child Protective

Services.

•

Fighting

or

name calling

is

not allowed

in

the

shelter.

•

No

running

in

the shelter.

•

Children

may

not touch or

use

the

stl.lVe

or

microwave.

•

Food

and

drinks

must

stay

in

the

kitchen

at

all

times_

•

Only

,go

Ot\tside

with

your

mother.

•

Beds

are

ll)T

~leeping

and

resting

only~

Do

not

play

on

the

bed

(or

tlther

fnrniture-)

• Child

may

nol

wunder

around

the

shelter without their

mom.

•

No

playing in

the

office-

staff

only.

• Children

are

not

to

answer

the

doors.

•

The

TV,

VCR

and

DVD

players

arc

to

be

operated

by

adults

only.

33. Employment

• After

you

find

employment,

you

are

responsible

to

buy

your

own

laundry

soap

and

hygiene

products.

• After

you

fi11d

employment

you

are

required

to

save

$200.00

u

month_

Executive

Director

will

put it

up

for

safe

keeping.

•

All

residents

must

be

working,

seeking

employment and

checking

for

available

services,

house

hunting,

attending

school, or

doing

volunteer

work

for

Hope

House

or

another

non-protlt

ot,ganization.

• After

you

have

a job

you

will

also

have

to

save

$50.00 a

month

to

put

towards

dn1g

tests.

If

you

do

not

save

the

money

we

will

assume

that

you

will

test

positive.

34.Smoking

•

NO

SMOKING WITHIN THE SHELTER OR

25

FEET

OF

ANY

ENTRANCE

TO

THE

SHELTER.

SMOKING

IS

ONLY

ALLOWED

IN

THE

DESIGNATED

AREAS.

All

cigarette

butts

must

be

place

in

the

cun

(not

on

the

ground),

packages

and

all

other

trash

must

be

put

in

the

trash.

If

you

are

caught

smoking

inside

the

shelter,

you

will

be

told

to

leave

at

once

and

if

you

are

found

smoking

in

a

non~designated

area

•

NO

going

out

to

smoke

after 1

0:30p.m.

or before

the

sun

is

up

35.Chores

• A

chore

schedule

will

be

presented

on

a

weekly

basis.

Housekeeping

is

done

with

cooperation

ol'a\1

re~idenls.

AU

residents

will

help

in

the

sl1elter

cleaning

and

taking

out

trash.

All

residents most cooperate

when

asked

to

help

with

cleaning

the

shelter

in

or outside

the

facility,

a resident

not

working,

at

school

or

doing

volunteer

services

may

be

asked

to

do

so,

if

deemed

necessary.

There

is

a chore schedule

located

outside

the

office door that

must

be

signed

daily

after

chores

arc

completed.

NO

EXCEPTIONS!

36.

TransportationN

ehicles

•

I{'

you

have

your

own

car

you

must

have

proof of

insurance

and

a

drivers

license

•

Hope

House

docs not have to provide transportation

to

anyone

for

any reason

•

It

is

the

residents responsibility

to

find

their

own

transportation, Hope

House

should

be

the

last

resort

• Must

have

approval

l(Jr

lransporlution

24

hrs

in

udvunce

• If

you

have

un

income

you

will

pay

$2.00

in

transpo1tntion

fees,

to

and

lrom,

if

you

use

Hope

House

transportation.

37.Changes

• From

time

to

time

it

may

become

necessary

to

make

adjustments

to

these

rules,

with

or

without

notice

and

at

the

discretion of

the

Executive

Director.

All

Services of

Hope

House

are

privileges

not

rights!

Hope

House

of

McAlester

Resident's Rights- All Services

Hope

House

ofMcAlester,

Tnc.

strives

to

provide confidential

quality

services

to

each

and

every

participant

who

requests assistance

from

this

agency.

Some

of

these rights are

directed

toward

shelter

.c;etting.

All participants shall

have

and

enjoy

all

constitutional

and

statutory rights

or

all

citizens of

the

State

of

Oklahoma

and

the

United

States,

unless abridged through due process

by

law

by a court

competent jurisdiction. Specific client

rights

shall

be

visibly

posted

and

are listed

below:

L

All

clients

have the right to

be

treated

with

dignily

and

respect.

This

shall

be

C011Structed

t.o

protect

and

promote

human

dignity

i:lnd

respect

2.

All

clients

have

the

right

to

a safe,

sanitary

and

humune

living

environment.

3.

All

clients

have

the

right

to

a

humane

psychological environment protecting

them

from

hann, abuse,

and

neglect.

4.

Each

client

has

the

right

to

an

environment

that

provides

reasonable

ptivacy,

promotes

personal

dignity,

and

provides

opportunity

for the client to imptovc

her

functioning.

5.

Each

has

the

right

to

receive services suited

to

her

needs

without

regard

to

her

race,

religion,

gender,

~exual

persuasion,

etlmic

origin,

age

and degree

of

disabiliiy,

handicapping

condition,

legal

status, and/or

ability

to

pay

for

services.

6.

Each

client, on

day

of

admissions,

has

the

absolute

right

to

comUlunicatc

with a

relative,

friend,

clergy

or

attorney,

by

telephone

or

mail,

at

the

expense

of the facility

if

the

client is

destitute.

7.

No

client

shaU

ever

be

neglected

or

sexually,

physically,

vcrbaHy

or

otherwise

abused

8.

Clients

!iha1l

have

the

right

to practice

her

own

religious

beHet:<:,

and

afforded

the

opportunity

for

religious

worship

that

does

not infringe on

the

health

or

safety

of

others.

No

client

shall

ever

be

coerced

into

engaging

in,

(lr

refraining from

any

personal

religious activity, practice,

or

belief.

9.

All

information

and

records

of

each client

shall

be

treated in a

confident1a1

manner

I

0.

Each

participant

shall

be

given

a periodic assessment

to

determine

the

appropriateness

of

her service/case

manngement

plan.

t

1.

Each

participant

shalt

retain all

rights,

benefits,

and privileges

guaranteed

by

law,

except

those

speciii.cally

lost

through

due

process

oflaw.

12.

Participant legally entitles

to

vote

shall be

assisted

to register

and

vote

if

they

so

request

13.

The

client's freedom

of

movement shall be restricted

more

than necessary

to

prevent

injury

tO

Se{

f

OT

Others)

to prevent

SUbstantial

damage

lO

property

and

to

provide

necessary

service!>

to

the

1esidcnt.

14.

In

general,

participanls

1nay

have

their

own

clothing

and

other personal

possessions,

This

right shall

be

forlbiled

ifth0 property

is

potentially

dangerous

to

the client,

others,

or

if the propetty

is

functionally

unsate.

Such

prope1ty

will

be

returned

to the

client

upon

their

depmture

from

the

l'aoi1ity.

Affidavit

of

Non-Liability

I,

---------------'

have

voluntarily

contacted

and

asked

Hope

House

of

McAlester,

Inc., for their available services

for

myself

and

roy

children

namely:

1

hereby

state

that

l

will

not

hold

Hope

House

or

any

person

acting

!"or

and

through

Hope

House

liable for their

acts,

and

l

do

hereby

promise

to

hold

them

harmless

for

said

act$

performed

on

behalf ofmyst;:l r or

my

children. I

understand

that

any

infonnation that

is

furnished

about

me

or

my

family

will

be

confidential

between

me

and

H<)pe

How;e

or any person

acting

for

and

through

Hope

House

to

the

extent

allowed

by

law.

Residont/Ciient

Signature:----------"--

Date:

_______

_

Intake

Staff

Signature:---------------

Date:

Statement

of

Understanding

and

Responsibility

T,

,

have

read

and

understand

the

resident

contract

--------------------------

and

rules

and

am

wBling

to

abide

by

the

contract

and

the

guidelines ofl-lope

House.

Of

my

own

free

will, I

am

entering this shelter to

provide

for

the

safety

of myself

and

my

children,

and

will

endeavor

to

cooperate

and

work

with

other

residents

in

this

communal

living situation. 1

have

also

been

infonned

of

my

rights. l understand that 1

will

be

responsible

for

the

care,

upkeep,

and

behavior

of

my

children and will

arrange

for

their

care

with

an

outside agency

(day

care)

or

family/friend.

Resident/Client

Signature:------------~

Date:

___________

_

Intake

Staff

Signature:

Date:

Sanctions

for

Terminating Residency

Hope

Honse

1s

a

safe

place

for

families

while

you

plan

your

Yonr

initial

contract is ibr

two

weeks

based

on

yonr

need

lhr

~helter.

Violating

shelter

1ules

and

policies

may

res\dt

in

your

stay being

tem1inated.

Living

in

the

l;helt.er

is

a privilege

not

u

right,

and

should

be

recognized

as

snch.

Since

the

shelter is a conununity-living situation,

it

requires

the

cooperatio11

and

clear

understanding ofthe

expeclaliom;

of

staff

and

residents. Discuss

any

questions

you

have

about

the

1ules

with

staff.

Reasons that a family may

be

asked

to

leave immediately

1.

Any

person,

chHd

or

adult,

caught

altering,

manipulating,

or

destroying

Hope

House

security system and/or cameras.

If

the

oft~nse

is

done

hy

a child,

lhe

entire

family

will

be

<1sked

to

leave.

2.

Any

kind

of

physical,

mental,

sexual~

or

otherwise

abuse

of

the

resident's child

or

other

resident's

children.

3.

Destroying

Hope

House

property

(shelter,

shelter

grounds,

or

any

building

thereof)

4.

Threatening

stuff,

physically

assaulting

staff

or

another resident.

5.

Obviously

under

the influence of

alcohol

or

drugs

and

disturbil'lg

othet

residents.

6.

Stay1ng

out

all night/missing 2

curfews

without

prior

approval

(adult

or

child.)

7.

Possession of

weapon,

drugs

or

alcohol

in

the

shelter.

Reasons

why

clients

may

be

asked

to

leave

in

24

honl's

1.

Possession

of

another resident's property (stealing.)

2.

Verbally

abusive

language

toward

stafl'or

other

residents and

unwilling

to

participate in

actions

to

resolve

the

situation.

3.

Unauthorized

per~on(s)

allowed

in

the residenes

room

(which

includes

Hope

House

client(s),

out~ide

family

or fdends.)

4.

Smoking in

room.

Reason why clients

may

be

given 7

days

to

leave

I.

Not

fulfilling

contract obligations. Staff

will

document

violatiorls.

(inciderltlwrite~up

in

file

offive

or

more.)

2.

Contract

date

complete.

(30-day

contract)

Forms

Effective

Tools

for

Organization

Accountability, integrity,

organization,

and

information: these are

what

fomts

help

achieve.

Fom1s

help

set

a

proces:>

in

place,

~upply

accurate

information

and

help

an

organization

develop structure

and

character. Fonns

must

be

presented

when

establishing policies

and

procedure~-

Each

form

plays

an

important

role

and

has

its

own

function.

Without

the

forms

there

would

be

no

structure,

no

accountability,

no

integrity,

no

organization

and

no

"paper trails"

within

Ilope

House.

h1

this

section you

wm

11nd

the

forms

we

usc

for

intake.

Each

fonn

is

designed

and

fom1atted

to fit different

needs

within

Hope

House.

These

forms

have been

created

as

the

need

of

arrival for

them.

As

Hope

House

grows

it

will

need

to

become

more

organized and

new

forms

will

be created. It is

also

wise

lo

review these

forms

every

couple

of

month~.

Thh;

way

new

ideas

ca1\

be

created

and

adjustments

or

in1ptovemcnts

on

the

forms

can

be

made

as

needed.

There

arc

many

different

forms

that

are

utilized through

Hope

House

and

they

all

have

different

functions:

Application

Procedure:

Th1s

i.e;

an

informative bulletin that

outline~

the

5lteps

to

take

the

clien.l

to

be

admitted

into

the

prog(am.

Client Intake Form:

Thi~

fonn

is

used

fot

the

client to

fill

out

at

intake

prior

to

being

accepted

into

Hope

House.

Rclctl.Se

Statement: This

form

is

used

for

tl1e

client

to

reJease

the

Hope

House

fi'om

any and

all

1iabililjes

during

their

time

at

Hope

House.

Client

Agreement:

This

fom1

is

used

for

the

client to

agree

to

abide

by

Hope

House's Policies

and

Procedure~

while

in

Hope

House

Program.

Medical

Request

Form:

This

fom1

is

used

for

the

client

to

request

penniss1on

to

go

to

the

doctor.

Meeting Request Form:

This

fonn

is

used

Jl)r

the

cHent

to

request

permission

fbr

a meeting with

program staff

or

pastor.

Pass Request Form: This

form

is

used

for

the client to request pennission to either have visitation

pass,

an

exwrsion

pass)

overnight

pass

or

weekend

pass.

Termination

Forn1:

This

form

is

used

when

a client is terminated

fi:om

the

program.

Safe Security Agreement:

This

!orin

is

used

tor

the client

to

fill

out

when

they

want

to

place

something

in the

safe.

W(lrk Order Form:

This

form

is

used

for

the other departments

or

agencies

requesting

work

to

be

perfbrrned

by

the

Hope

House.

Scripture Mcmol'izntion Wot•ksheet:

This

is for the client

to

use

to

work

on

their weekly

memory

verse.

Hope

House of McAlester

Consent for services/ Confidentially

Consent to receive Services

l consent

to

receive

psychological

evaluation, diagnostic

procedure,

and/or

s~tpport

services

from

Hope

House

in

McAlester,

OK.

The purpose

of

these

procedures

wit1

be

explained to

me.

I

understand

that

conse11ting.

to

services

does

not

waive

my

rights

under

federal

and

state regulations.

Confidentiality

I

under::;tand

that

my

communication with

Hope

House

any

my

treatment records

ure

confidential

any

may

not

be

released

except

under

the following conditions/circumstances or

where

otherwise provided

by

federal

and

state regulations,

such

as:

• 1

give

my permission

by

written

:inHmned

consent.

• A court

so

orders.

•

My

guardian gives pennission.

•

Upon

the

need

to

disclose infonnation

to

ptotect the rights

and

saH~ty

of

myself or

others if:

o I present a clear

and

present danger

to

mysel

rand refuse explicitly or

by

behavior

to

voltmtarily

accept

appropriate services:

OR

o

Ifl

comnuu~icate

an

explicit threat

to

kill

or

inllict serious bodily injury

upon

an identified

person

with

the intent

and

ability

to

carry

out

the threat:

OR

o

1f

1 have a

known

history

of

physical

violence

and

the treatment staff

has

a

reasonable basis

to

believe

that there

js

a clear

an<\

imminent danger that 1

will

attempt to

kill

or

inflict serious bodily injury upon

an

identified

person

•

The

reporting of alleged

acts

of

child

~bt1Se

at1dlor

neglect.

Records

are

kept

in

locked

Illes

and are

only

seen

by

authorized

personaL

The right

to

privacy

and

confidentiality

is

u great

coneem

to

the entire

Hope

House

staff:

Consent Release Statement

I~------------~-->

understand

that

my

acceptance

as

a client

in

the

Hope

House

requires

the

following:

1.

1

am

a volunteer patiicipant

and

not

an

employee of

Hope

House

or

any

of

its

affiliates. I

further

understand

that

under

no

circumstances

can

Hope

House

or

any

of

its affiliates be

under

any

obligation

to

me.

2.

I understand that

my

admission and continued

residence

in

Hope

House

is

dependent

upon

my

needing

such assistance and

my

willingness

lo

help

myself

and

others

~o

situated,

including

the

voluntary

perfotmance

of

such

duties

as

may

be

assigned

to

me.

3.

I

am

aware

of

the

hazards

and

risks

to

my

personal

pl'Opelty

associated with being a

part

of

this

Progrum.

Such hazards

and

risks

include,

but

arc

not

limited

to,

death,

injury

by

uccidet1t,

disease,

weather conditions,

inadequate

medical

services

and

supplies,

criminal

activity,

and

illness associated

with

such

risks,

and

any

damage

to

my personal

propetty.

I

further

understand

that

Hope

House

or

any

ol'its aflltiates

may

not have

any

insurance

coverage

lhut

would

apply

in

the

event of

my

death,

illness

or

damage

to

my

person

or

propetty that

may

occur

during

my

patticipation in

the

Program.

If I

desire

insurance

coverage,

I

understand

that I

am

responsible

for

obtaining

and

paying

for

the

cost

of

such insurance.

4. I

re1eas~

Hope

House

and

its

affiliates, agents, officers,

directors,

employees and

volunteer

staff

from

any

liability whatsoever arising

us

a result

of

death,

injury

or

illness that l

may

suffer

as

a result

of

my

pcniicipation

in

the

Program.

5.

I attest

and

certify that 1

have

no

medical conditions that

would

prevent

me

from

performing

my

duties

as

a volunteer participant.

6.

1

cxptesHiy

waive

any

defense

to

the

enforcement

of

any

of

any

provision of this

commitment

arising

from

a

claim

of

Lack

of

consideration

and

warrant

that

this

commitment

constitutes

a

legal

valid and binding

obligation

~tpon

me

enforceable

against

me

in

accordance

with its

tenn~.

7.

I expressly

agree

that this

assumption

of

risk

agreement

is

intended

to

be

as

broad

and

inclusive

as

permiUed

by

Jaw.

I further state that I HAVE CAREFULLY

READ

THE

FOREGOING ASSUMPTION

OF

RISK

AND

UNDERSTAND ITS

CONTENTS,

AND

I VOLUNATRIL Y SIGN THIS RRLRASE

AS

MY

OWN

FREE ACT. THIS IS A LEGAL DOCUMENT

AND

I

UNDERSTAND

THAT I

HAVE THE

OPPORTUNITY TO CONSULT WITH

AN

A'f'l'ORNEY

BEFORE

SIGNING

IT.

Hope House

Client Agreement

I,------.,.-----------)

understand

that

my

acceptance

us

a client

in

Hope

House

requires

the

following:

1.

HOUSE RULES, MORAL

STANDARD,

AND

WITHDRAWAL FROM SUBSTANCE.

I

have

read

and

understand

House

rules

as

provided

lOme,

and

undetstand

that such

House

Rules

may

be

amended

upon

the Program's discretion, with

or

without

notice.

Accordingly,

I

agree

to

abic.le

by

all

Programs'

rules)

including

but not

limited

the

House

Rules

as

given

to

me.

In

addition,

I

agree

to

abide

by

the

moral

standards

as

upheld

in the

Bible.

I understand

that

all

forms

of

sexual

activity are prohibited and

will

abide

by

such

accordingly.

Furthem1ore,

I

undcrst~md

that the Program is a

drug

and

alcoholiree,

BUT

DOES NOT serve

as

a

detoxil1cation

facility.

Accordingly,

l

agree

to

withdraw

from

any

and

u.ll

substance

dependence

voluntarily

ami

without

the

use

of

medication.

2.

MEDICAIJ RELEASE. I

hereby

authorize the

Program

to

make

arrangement$

tor

any

emergency

medical

assistance

that

may

be

required

due

to

any

illness

or

injury

on

my

part.

3.

HOPE HOUSE HIV POLICY.

Hope

Hou~e

does

110t

discriminate against those

who

are

HIV

Positive

in

its intake procedures.

Because

a

large

number

oCTV

drug

users

have

been

infected

by

th~

I-IIV

Viru~)

at

a11y

given

time there

may

be

one

or

more

residents

in the

program

that arc

HIV

positive.

This

program

does

not

reqttire

residents

who

are

HIV

Positive

to

notify

any

other

residents

in the

program

that

ure

HIV

Positive.

· Htaffmcmbers

are

forbidden

without

written permission

of

a resident

to

discuss that

dispo~ition

of

any

client

on

her

cascload;

other than those individuals that

are

involved

in

the treatment

proces::>.

Hope

House

is

not''

medical

care

facility

and

is

unable to

provide

24

hour

on~sitc

medical

supervision.

Therefore,

ull

women

entering the program

must

be

in

good

health

and

able

to

participate in

all

activities

in

the

program.

Ira

resident's

health

deteriorates

to the point

where

she

is

no

longer

able

to

patticipate

in

the

daily activities oflhe

prograni)

or

medical

condition

req~tires

24

hour

medical

supervision, that

person

should leave

H~)pe

House.

1-IIV

Positive clients

who

have

family

members

or

friends

who

could

have

possibly

contracted

the

vims

from

them

shall

notify

immediately.

Any

HIV

Positive client that intentionally

put~>

~mother

person

at risk

of

being

infected

with

HIY

virus should

be

immediately

dismissed

from

the program.

4.

RltLEASE OF CONFIDENTIAL CASE FILE

AND

COPYRIGHT TO PERSON

AND

STORY.

Thereby

release-and

grant

Hope

House,

its

agents,

affilifltes

or

third

party

as

designed

by

the

Program

all rights

to

use

and

publish

for

any

lawful

purpose

whatsoever

to promote the

Program's

purpose

my: l) confidential infonnation

as

c:Qntained

in

my

program's

case

file;

2)

personal

story;

and

3)

name,

likeness,

or

appeara.n<.:e,

I understand that I

may

also

be

requested

to

speak

at

public

gatherings,

give

testimony

or

participate

in

the Program's

activities

whereby

T

may

be recorded

in

any

fonn

or

manner.

Accordingly, I

hereby

release

and

grant

the

program.

to

~u;e

such

recordings

of

me

whatsoever

to

promote

the program's

purpose.

I

also

hereby

waive

any

right

to

inspect

or

receive

a

copy

of

the

finished

product.

1

hereby

release

and

discharge the

progmm_,

its agents, arf\liates or third party

as

designated

by

the

Program

any

and

all liability

by

virtue

of

misprit1t,

error

or

distortion that

may

occur

unless

it

can

be

shown

that

such

error,

misprint,

or

distortion

were

maliciou~ly

based.

·I

further

understand

that I

v.~llnot

be

compensated

in

any

form

for

any

and

all

use

of

my:

1)

confidential infonnation

as

contained in

my

program's

case

file;

2)

personal

story;

and

3)

name

likeness,

or

appearance.

5.

RELIGIOUS REQUIREMENTS. I

understand

that

the

program

is a Clnistian

based

ministry

program

to

assist

people

with

life controlling

problems.

Through

my

parlicipation

in

this

program>

I

agree

to

submit

to

the

program's religious

expectations

and

attend

the

pro

grant's religious activities.

6.

CONSENT TO DRUG TESTING

AND

CON'l'RACTED WEAPON SEARCHES. I understand

that

program

is

a

drug

and

weapon

free

facility

for

the

safety

and well

being

of

all its

clients,

employees,

and

vohmtccrs.

Accordingly,

by

my

participation

and

consent

below,

1 hereby

voluntarily consent to all drug tests

on

myself and all contraband and weapons searches of

me

and

my

Jiving quarters upon request.

I understand

that

the

results

of

my

drug

tests, if

any,

will

only

be

disclosed to

Hope

House

and

all legal authorities

Hop~

Hous0

de~ms

necessary. I understand

that

if

I

am

tested positive

for

any bamted drogs

that

are

listed in Hope House's

Drug testing

and

Contraband Search Procedure

brochure,

the Hope House may

terminate

my

participation in

the

Program, Furthcrmm·c, Hope House

may

terminate

my

participation if

there

are any drugs,

contraband

items

or

weapons

found in

my

living quarters or

on

my

person.

FO~MS

Client

Intake

Form

Intake

Date.

__

_

Personal

Information

..

,,

..

~

..

·-

Last

Name:

First

Name;

Date

of Birth:

Spouse

~an:~

ID

Number:

~Typo'lfJO,stn&~

Sacral

Security#:

Address:

THome\ess:

f

DYes

ONo

City

State:

I

Zip

Code: J

:-----

"'

.

.-.

Home Phone:

Work

Phone:

Cell Phone:

Fax:

Age:

I

Sex:

I

DMale

DFemale

Height:

I

1/l(~ight:

I

.

Religion:

Race/Ethnicity:

cDlB

Marital

Status:

o

Mafiiea-

a••~o·

D'iVorced

..

·--

0

SinQie

0 Widowed

Emergency

Contact

Person;

I

_I

Relationshjp: I

Emergency

Ph

#:

I

Secondary#:

Emergency

Address:

Do

you

have a

car?

0

Yes

ONo

If yes

who

will

take

care of it while you are in the

program?

Are

you

currently receiving

any

type

of

income? 0 Yes 0

No

If

yes,

please

explain:

Have

you

ever

been in the military? D Yes

DNo

Discharged?

DYes

DNo

If

dishonorable discharge please explain.

Education

Circle last year completed:

-

....

"'

Primary~

1 2 3 4

5

6

7 8 9 10

11

12

CoUege:

1

2

3 4 +

-·'·

Can you read and

write?

DYes

DNo

Can

you

speak

English? 0 Yes

ONo

..

···-

Have you

ever

been

in special education classes? 0 Yes

DNo

,...._

.

..,

Religious

Background

Do

you

believe

in

God?

DYes

D No

o

Uncertain

Have you ever acamtod

.kl:su$

ClifM: as your Savio!? 0 Yes D

No

0

U~rtaln

Are

you

attending

church

now? 0 Yes

0

No

If

yes,

where?

r..-.4•

.-..

fORMS

Legal

History

Have

you

ever

been

arrested?

D

Yes

D

No

How

many

times?

_____

_

If

yes,

give

details:

Have

you

ever

done

jail

time?

D

Yes

D

No

If

yes,

what

for

and

how

long?

Are

you

on

probation

or

parole?

D

Yes

0

No

If

yes,

give

probation

or

parole

officer's

contact

information

below:

Are

you

court

ordered

here?

0

Yes

D

No

If

yes,

give

contact

information

regarding

your

court

case:

Do

you

have

any

legal

charges

pending?

D

Yes

D

No

Where?

What

are

the

charges?

Do

you

think

you

may

have

any

outstanding

warrants?

DYes

0

No

If

yes,

please

explain:

Do

you

have

any

other

pending

legal

matters

that

would

require

you

to

attend

to

in

the

next 90

days?

DYes

0

No

If

yes,

give

details

below:

-49-

FORMS

Drug

History

Have

you

ever

used

drugs?

DYes

o

No

If

yes,

how

old

were

you?

Why

did

you

ttY

them?

0

To

help

me

deal

with

life.

0

Some

of

my

family

use

drugs.

D

To

escape

reality.

D Justfor

fun.

0 To fit

in

with

my

peer~.

D I'm

bored.

tJ

My

friends

use

drugs.

0

Curiosity.

0

To

make

physical

pain

go

away.

0

Other:

CJ

ro

make

emotional

pain

Qo

away.

Have

you

ever

sold

drugs?

0

Yes

D

No

Do

you

think

you

have

a

problem

wlth

drugs?

0

Yes

D

No

0

Uncertain

Explain

why

or

why

not.

Since

you've

been

uslng,

what's

the

longest

period

of

time

that

you've

been

sober?

Please

fill

out

information

below

concerning

your

dru

use.

Drug

First Time

Last Time

Frequency

Amount

Used

(If you

dlcJ

no/use

drug

If

sled

(How old

w~:~rv

you

Qr

(How

of/Gn

dlcf

you

use

(How

much did you

use

leave blank,

if

drug

is not

(Approximate

date?)

listed fill in}

what month/yeai?}

d!)i/y,

weekly,

monthly)}

per

daylweeWmonlh?)

Alcohol

Barbiturates

Benzodiazepines

Cocaine/Crack

Glue/Paint

Heroin

lnhalants(Snuffing)

LSD

Marijuana

MDMA

(Ecstacy)

Meth

Mushrooms

PCP

Prescription

Drugs

Speed

Tobacco

Other:

-50-

I'ORMS

Medical

History

Date

of last

physical

exam:

Results:

List

any

phy$ical

ailments

or

handicaps

that

you

may

have:

Date

of last dental

exam:

Results:

List

any

dental

problems

you

may

have:

Date

of last

eye

exam:

Results:

Do

you

wear

glasses?

I

DYes

0

No

I

Do

you

wear

contacts?

T

DYes

DNo

List

anything

that

you

may

be allergic

to:

.

Have

you

ever

been:

Diagnosed

with

ADD?

DYes

D

No

When?

Diagnosed

with

ADHD?

DYes

D

No

When?

Diagnosed

with

any

Mental

Disorder?

DYes

0

No

When?

Diagnosed

with

Tuberculosis?

DYes

0

No

When?

Diagnosed

with

Hepatitis

A?

DYes

D

No

When?

Diagnosed

with

Hepatitis

B?

DYes

D

No

When?

Diagnosed

with

Hepatitis

C?

DYes

D

No

When?

Diagnosed

with

HIV

Positive?

DYes

0

No

When?

Diagnosed

with

AIDS?

0

Yes

D

No

When?

Diagnosed

with

Herpes?

DYes

0

No

When?

Diagnosed

with

any

STD?

DYes

D

No

When?

Diagnosed

with

Body

Lice?

DYes

D

No

When?

Diagnosed

with

High

Blood

Pressure?

DYes

D

No

When?

Diagnosed

with

Heart

Disease?

DYes

DNo

When?

Diagnosed

with

any

other

illnesses?

DYes

D

No

When?

-51

-

FORMS

Do

you

currently

have

any chronic

medical

conditions

not

listed

above

that

require

regular

visits

to

the

doctor? 0

Yes

0

No

If

yes,

please

explain:

Are

you

presently

on

any

medication?

0

Yes

0

No

(If

yes,

please

list

below

and

give

reason

for

taking

it.

Have

you

ever

been

admitted

to a

hospital?

D

Yes

D

No

(If

yes,

please

explain

below.

Are

you

physically

able

to

perform

all

assignments

(you

must

be

able

to

lift

25

lbs,

be

able

to

stand

for

long

periods of

time

as

well

as

climb

up

to

4 flights of

stairs)

as

part of

this

program?

0

Yes

D

No

If

no,

please

explain:

Have

you

ever

been

diagnosed

with

any

mental

condition?

D

Yes

0

No

If

yes,

please

explain:

Have

you

ever

been

under psychiatric

care

or

been

admitted

to

a

mental

health

institution? 0

Yes

0

No

If

yes,

please

explain:

•52-

FORMS

Sexual

History

Have

you

ever

contracted

a

sexually

transmitted

disease?

DYes

0

No

If

yes,

please

list

disease,

when

and

how

it

was

treated:

Have

you

ever

been

the

victim

of

sexual

abuse?

0

Yes

D

No

lffemafe,

are

you

currently

pregnant?

DYes

D

No

D

Uncertain

Have

you

been

pregnant

In

the

past?

DYes

D

No

0

Uncertain

If

yes,

what

was

the

result

of

the

pregnancy?

D

Miscarriage

0

Abortion

D

Birth

Do

you

have

any

children?

0

Yes

D

No

If

yes,

how

many

and

what

are

their

ages?

If

male,

are

you

the

father of

any

children?

0

Yes

D

No

0

Uncertain

If

yes,

how

many

children

do

you

have

and

what

are

their

ages?

Have

you

ever

been

involved

In

prostitution?

0

Yes

ONo

Have

you

ever

been

involved

in

any

homosexual

behavior or

activities?

0

Yes

0

No

Do

you

consider

yourself

to

be

...

0

Heterosexual

(straight) 0

Bisexual

0

Homosexual

(Gay/Lesbian)

Goals

What

goals

do

you

have

while

in

this

program?

What

do

you

want

to

happen

in

your

life

while

you

are

in

this

program?

-53.

FORMS

Reason

for

placement:

(Check

all

of

the

following

that

apply

to

yof.lr

situation}

Problems

with

primary support

group

D

Death

of a

family

member

D

Health

problems

in

famify

D Disruption of family

by

separation

D

Disruption

of

famify

by divorce

D Disruption of family by estrangement

D

Removal

from

home

D

Remarriage

of parent

0

Sexual

abuse

Problems

the

social

environment

0

Death

of a friend

D

Loss

of a

friend

0 Inadequate soclal support

D

Living

alone

0 Difficulty

with

acculturation

(being

accepted

by your

own

culture)

Educational problems

0

Illiteracy

0

Academic

Problems

D

Discord

with

teachers

D

Discord

with

classmates

Occupational

problems

0 Threat of job loss

0 Stressful work

schedule

0

Late

for

work

0 Difficult

work

conditions

0

Job

dissatisfaction

Housing

problems

0 Homelessness

0 Inadequate

housing

0

Unsafe

neighborhood

Economic

problems

0 Extreme poverty

0 Insufficient welfare support

Problems

with

access

to

healthcare

services

0 Inadequate health

care

services

D Transportation to

health

care

unavailable

~54.

o Physical

abuse

0 Verbal

abuse

D Parental

overprotection

0 Neglect of

child

·

0 Inadequate discipline

D Discord

with

siblings

0 Birth of a

sibling

D

Other;---------

D Discrimination

0 Adjustment

to

life-cycle transition

(not

adjusting

to

changes

in

life)

D Other;

_____

_

___

_

D Inadequate

school

environment

0

Late

for

class

0

Other:

_________

_

D

Job

change

D

Discord

with

boss

0 Discord

with

co-workers

0

Other;

________

_

0

Discord

with

neighbors

0

Discord

with

landlord

D

Other;~~~---~--

D

Other;------~--

0 Inadequate

health

insurance

D

Other;--~----~--

FORMS

Problems related to interaction with the

legal

system/crime

0 Arrest 0 Vandalism

0

Incarceration

tJ

Arson

0

Litigation

0 Probation

0

Victim

of

crime D

Other;--------~-

0 Stealing

Other

psychological

and

environmental problems

0

Exposure

to

disaster

0 Involved

in

war

0 Involved in a hostility

D Discord with counselor

0 Discord with

social

worker

D Discord with

physician

D Discord

with

minister

o

Suicide

0

Eating

disorders

Other

Abuse Problems

0 Alcohol Abuse

0

Drug

Abuse

D

Verbal

Abuse

toward

others

0 Physically abused

others

Spiritual

Histol)'

0

Ouija

Boards

0 Satanic Worship

0 Witchcraft

D Levitation

0

Palm

Reading

0

Fortune

Telling

D Voodoo

0

Astroprojection

D

.Seances

0

Tarot

Car'ds

D Cutting I Self-Mutilation

D

Low

self-esteem

0 Lack of motivation ·

0 Lying

0 Problems with authority

D Manipulative

behavior

0 Unavailability

of

social

service

agencies

D Other:

________

_

0 Sexually abused others

0

Pornography

0

Sexual

addictions

0

Other:---~~---~

o

Horoscopes

0 Yoga

D

NewAge

0

Mormonism

D

Scientology

0

Buddhism

0 Hinduism

0 Transcendental Meditation

D Jehovah's Witness

0

Other:------~-~

What

are some

other things

you've

tried?

(Check

all

of

that apply

to

your

situation)

0

Individually

Counseling 0

Attended

Parenting

Classes

D Family

Counseling

0

Boot

Camp

0 Informal

Probation

0 Boarding School

0

Formal

Probation

0 Hospitalization

0 Called Police D Psychiatfic Evaluation

0

Changed

Schools 0

Medications

0

Changed

Jobs

0

Other:,

_______

~-

How

did

you

hear

about

us?

(Check

all

of

that

apply}

0

Friend

0

Billboard

0

Family

Member

D

Brochure

I

Flyer

0

Church

Leader D

Other:~--------

55

CLIENT

INTAKE

FORM

INTAKE

DATE.

____

~-----

LAST

NAME~-----

FIRST

NAME:._

______

SPOUSc

NAME

_________

~-

CHILDREN;

NAME,

AGE

AND

SEX·-~---------

AGE~_OOB.__

____

.HT_WT

__

~:;.nr,J=r

_____________

lDff

__________

__

:·

ADDRfSS

______

~------··_.

·_·

-~-CITY

__

~---~·ST_ZIP_~

HOM£

PHONE

____

~_CELL'--

______

WORK.

___

~~--

RELIGIOUS

PREfERENCE

_____

~~-DO

YOU

AITENO

CHURCH

NOW?

YES

NO

WHERE

____

~

RACE/EIHNICIIY:

A

AA

H

ME

NA

W

CDil3?

Y N

MARITALSTATUS:

Single

Married

Divorced

Widowed

EMERGENCY

CONTACT;

NAME'------~------PHONE.

_______

_

ADDRESS

________

~

___

CITY

_______

SI

__

ZIP

_____

_

DO

YOU

HAVE

A

CAR?

YES

NO

INCOME?

YES

NO

TYPE

________________

_

VETERAN?

YES

NO

HIGHEST

GRADE

COMPLETED:

1 2 3 4 5 6 7 8 9

10

11

12

COLLEGE:

1 2 3 4

CAN

YOU

READ?

YES

NO

DO

YOU

SPEAK

ENGLISH?

YES

NO

WERE

YOU

IN

SPECIAL

EDUCATION

ClASS!:$?

YES

NO

00

YOU

HAVE

A

CRIMINAL-RECORD?

YES

NO

FOR

WHAT?~---~---------~-

CHARGES

STILL

PENDING?

YE$

NO

ARE

YOU

ON:

PROBATION

PAROLE

DRUG

COURT

DO

YOU

HAVE

A

PROBLEM

WITH

DRUGS

OR

ALCHOL?

YtS

NO

LAST

'f!M(;

YOU

USED?

_____

~

DRUG

OF

CHOICE~------~~--

LIST

ANY

PHYSICAL

AILMENTS

OR

HANDICAPS

THAT

YOU

MAY

HAVE;·--~-~-~-~------

UST

ANY

ALLI:RGIF.S

THAT

YOU

HAVE:_~--~-----------------

LIST

MEDICATIONS

CURRENTLY

TAKING:.

___

~----------------~-~

---~~-----------------~'"--~~-

ARE

YOU

PHYSICALLY

ABLE

TO

PERFORM

ALL

ASSIGNMENTS

(YOU

MUST

BE

ABLf

10

LIFT

25

LBS.,

BE

ABLE

YO

STAND

r:GR

LONG

PERIODS

OF

TIME

AS

WELL

A$

CLIMB

UP

TO

4

FLIGHTS

OF

STAIRS}

AS

PART

OF

THIS

PROGRAM

YES

NO

IF

NO,

PlEASE

EXPLAIN

__

~------~---------------~--

HAVE

YOU

EVER

BEEN

DIAGNOSED

WITH

A

MENTAL

CONDITION?

YES

NO

IF

YES,

PLEASE

EXPLAIN

_______________

~-~------~--~

HAVE.

YOU

EVER

BEEN

ADMITIEO

TO

A

MENTAL

HEALTH

FACIUlY?

YES

NO

IF

YES,

PlEASE

EXPlAIN.

_____

~------~-~---~-------~~

PLEASE

DESCRIBE

THE

EVENTS

THAT

LED

YOU

TO

BEING

HOMELESS.

-~~-~---

WHAT

ARE

YOU

GOALS

WHILE

IN

THIS

PROGRAM;·---~--~--~~---~-------~

PERMISSION

TO

OBTAIN

EMERGENCY

MEDICAL

CARE

I agree

to

Jet

a

Hope

Hovse

staff member

or

ambulance

to

transport

me

ancl/or

my

dependents to the nearest medical

facility

in

an

emergency

in

the

case that l

am

incapacitated or unable to

accompany

my

dependents. I

agree

to let the

dodOr·on·call treat

me

(if I

am

incapacitated) or

my

dependents for

emergency

care.

Signing

this

form

devoid staff

of

liabilitx

in

an

emergency

situation.

Resident/Client

Name

(please

print)

________

_ _ _

______

_

Resident/Client

Signature

--

-----~----___:Staff

Witness.

_ _ _ _

________

_

Child/Dependent's

N~;~me--------

-----

---~-~

Date

of

Birth

______

_

Child/Dependent's

Name.

_

____________

____

__

Date

of

Birth·

-

~-----

Child/Dependent's

Name.~--

----

-

--------

-

--

Date

of

Birth

______

_

Child/Dependent's

Name

__________

____

_____

Date

of

Birth.

______

~

Child/Dependent's

Name

_________

_

____

__

___

Date of

Birth~~~---

Child/Dependent's

Name·------------~~-----

DClte

of

Birth

______

_

Who

should the staff contact concerning

your

care should you

b~come

incapable

of

making decisions

for

your.s~lf?

Name:·--

-

----------~---~

Relationship

____________

_

Address:

___

__

___

~-------

~

~--

~_Phone

_____

__

_ _

__

_

Name=

-

--------

-

-----~--

Relationship

____

~~-------

Address:

______

~-----

-

--------~Phone

_ _

_____

____

_

Record

of

Emergency

care

Rec'd:

Date

____

Time:

___

~

-

Medical facility

:.

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Description ofinjury

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-

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-

---

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Date

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Time:

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_

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Medica[

Facility

:

____

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of incident (attach

documentation

as needed)

-~-----

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--~------

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Fill Online, Printable, Fillable, Blank Hope House McAlester %28women%29 Application Hope McAlester (women) application.pdf Form

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