Waypoint for Substance Use Disorder Recovery

Your Information

Name *

First

Last

Email *

Current Address *

Address Line 1

City

State

Zip Code

Phone Number *

Cell Phone Number

Date of Birth *

Social Security Number (Last 4 Digits) *

Employer Information

Employer Name

Employer Address

Address Line 1

City

State

Zip Code

Employer Phone

Emergency Contact and Release of Information: (Full Name, City, State, Phone Number & Relation)

Treatment Information

Current Treatment Provider

Treatment Provider Address

Address Line 1

City

State

Zip Code

Treatment Provider

Primary Counselor

Primary Counselor Contact Number

Length of Stay at Treatment Facility

Tentative Discharge Date

Past Treatment Program #1 (Name, City, State, Counselor, Entry/Exit Date)

Past Treatment Program #2 (Name, City, State, Counselor, Entry/Exit Date)

Have you ever lived in a Half-way, 3⁄4, or Transitional Living Home? *

Substance(s) Used In Past?

Substance(s) of Choice?

Sobriety Date

Which 12-step recovery program are you working, i.e. AA, NA, CR?

What meetings do you attend regularly?

Do you have a Sponsor? *

Personal Life

What is your current source of income?

Weekly/Monthly Income?

Job Description

How long there?

Employer Name

Employer Address

Address Line 1

City

State

Zip Code

Employer Phone Number

Do you have a valid driver license or state ID? *

Do you have a Social Security Card for employment? *

Do you have a child support obligation? *

Legal Information

Do you now, or have you ever been in a relationship with a current Waypoint Wabash program participant? *

Pending legal matters (Please explain)

Have you ever been convicted of a felony? *

Are you currently incarcerated or under community supervision (probation, community corrections)? *

Are you required to register as a sex /violent offender? *

Have you been convicted of arson? *

Do you have any other mental health diagnosis? *

Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors? *

Current Medications and Dosage

Are you participating in or about to enter a buprenorphine (suboxone) or another drug replacement program? *

Final Questions!

How did you hear about us?

Why do you think you are a good fit for a transitional living home?

Applicant's Name *

First

Last

Applicant's Electronic Signature *

Program Agreement

Waypoint Wabash and you agree to the following program terms.

1. The program fee is $120.00 per week.

2. The program fee includes room and utilities only.

3. An initial payment of $480.00 is required to move in, this will include the first two weeks program fee and security/sobriety deposit of $240.00. Payment must be made with either cash or money order, no personal checks will be accepted. Deposits will be returned within 10 business days of program completion.

4. Management requires one-month notice when program participant is leaving on good terms.

5. There will be no refunds (including deposit) for dismissal, leaving before 9-month commitment is up, theft of property by a program participant, physical force against another person living in the house, or leaving without providing a one-month notice.

6. Failure to follow any house rules may result in immediate termination from the program, and there will be no refund of program fees paid.

7. The program fee is due weekly at the house meeting, beginning with the first house meeting after the participant begins.

8. Program participants are responsible for their own food, personal hygiene products, and telephone.

I understand and agree to the above terms.

Applicant's Name *

First

Last

Applicant's Electronic Signature *

Program Guidelines

1. I agree not to consume Alcohol and/or Drugs while residing at this property. If I am taking prescription medications (non-narcotic only apart from Medication for Opioid Use Disorder) that are prescribed by a doctor, I will provide that information at the time of initial intake and discuss further use with management. If I am prescribed prescription medications (non-narcotic only, apart from Medication for Opioid Use Disorder) by a doctor during my stay at this residence, I will contact the House Manager immediately to discuss this. I will also discuss any over the counter medications with management PRIOR to taking them. I further understand that it is my responsibility to avoid ingesting anything (including food), that may cause a false positive reading during drug screens. I understand that if staff believes that I am under the influence, I am subject to discharge even if a drug screen produces no illicit substance present. Individuals on Medication for Opioid Use Disorder agree to have the levels of the medicine randomly checked to confirm compliance with their treatment regimen.

2. I agree to take random screens for drug and alcohol use administered by management upon request. If the test has a reading for illicit substance use, the program participant will be asked to leave the house immediately. If a program participant is unable to produce a urine sample within 1 hour of the request of the house manager, the urine drug screen/breathalyzer will be considered positive. If for some reason the test is inconclusive, or the manager is uncertain about the results, the program participant will be asked to have a drug screen/breathalyzer performed at an independent laboratory at the discretion of the manager. If that test has a reading for illicit substances (excluding those participating in a Medication for Opioid Use Disorder program producing licit use results), the program participant will be asked to leave the house immediately.

3. I agree not to steal others’ property while I am a program participant of the house. This includes personal property and food belonging to the agency or any other program participants of the house.

4. I agree not to use physical force against anyone in the house while a program participant of the house. This includes threatening and/or verbal harassment of other program participants or management.

5. I agree to pay my program fees on time and in full each week at the house meeting.

6. I agree within the first 30 days to actively seek and obtain full time employment. Employment hours may be substituted with volunteer hours, classes and outpatient treatment if approved by the House Manager. The hours of employment must be during a first shift job (home by 6pm at the latest). Our program defines full time employment as 32 hours.

I agree that if I call in sick / call off work I will not be allowed anywhere else outside of the house that day. If I miss any meetings, I will be responsible to make them up during that week.
I agree that if I leave employment / quit my job without notice or have another job in place, I will be on restrictions until I get another job.

7. I agree to follow the curfew, which is 10 PM - 6 AM Sunday through Thursday and 11 PM - 6 AM Friday and Saturday. In the event I am unable to make curfew, I will contact the House Manager to discuss this prior to the curfew.

8. I agree to attend a minimum of five recovery meetings (Alcoholic Anonymous, Narcotics Anonymous, Celebrate Recovery, Bible Study, others as approved) per week if I have less than one year in recovery and a minimum of four meetings per week if I have over one year in recovery. The house meeting on Sunday at 6:00 PM is mandatory. The time of this meeting is subject to change, to be determined by house management.

9. I agree to find a sponsor and start step work within the first 30 days. I agree to continue doing step work during my entire stay in our program.

10. I understand that overnight stays away from the program are a privilege and must be cleared with the House Manager 5 days prior to the date requested. Failure to be in the house after curfew will be viewed as a violation of rules, and the program participant will be discharged.

11. I agree to attend a church service weekly at the church of my choice.

12. I agree to seek outside mental health services or screenings if required by management and to sign releases allowing the staff to talk with these clinicians. I also agree to seek immediate mental health services if there any concerns regarding my safety or the safety of other program participants.

13. I understand that during my first week at the house I am not to leave the property unless I am with another program participant. Exceptions to this are work, court related appointments, and therapy.

14. I understand that during my first month at the house, if I like to leave Wabash County for any reason, I must complete a house pass request form and have it approved prior to leaving.

15. I agree to show financial responsibility if I bring a motor vehicle on the property, I will provide a valid driver’s license, valid registration, and proof of insurance coverage. Parking privileges will not be provided by facility. I understand that it will be my responsibility to obtain parking off facility property.

16. I agree to keep my room clean and orderly, make my bed every morning, as well as maintain the cleanliness of the common areas, daily and as needed.

No food or drink is allowed upstairs including in your bedroom.

17. I agree to do the weekly chore that is outlined by the Chore Coordinator when assigned and to participate in any special projects that are requested by the House Manager. I understand that chores are to be done on Wednesday and Sunday by 6 PM at a minimum. I agree to check them daily, and clean, as necessary.

18. This residence is smoke-free & vape-free. There is no smoking/vaping inside the house at anytime. Smoking/vaping in the house will result in immediate dismissal. Smoking/vaping is allowed outside only in designated areas. Cigarette butts must be disposed of properly.

19. No overnight guests will be allowed, including family members. Any guests will be limited to the common areas of the house and must be substance use free for a period of 60 days prior to their visit. No non-program participants are permitted off the 1st floor of the facility(s) without prior management approval. Program participants should bring the presence of questionable guests to the House Manager’s attention immediately.

20. I will not engage in an intimate relationship with any other program participant of a Waypoint Wabash facility.

21. I agree to commit to a minimum of a 9 month stay if this my first attempt in the program and a year stay for any subsequent attempts. If I leave early, I forfeit my security deposit.

22. I agree to retrieve my belongings and personal effects no later than 72 hours after leaving the residence. I understand that if I do not, they will be donated to charity.

23. I agree to inform the House Manager if I know that another program participant has had a recurrence of use. Failure to do so will result in my dismissal.

24. Quiet hours are from 10pm to 9am. Program participants must be out of bed by 10am.

25. Do not go into any other program participants’ rooms when they are not present. In case of an emergency, two people must be present, and the House Manager must be notified. I have read and fully understand the program guidelines, I understand they are subject to change at any given time, as management requires.

Applicant's Name *

First

Last

Applicant's Electronic Signature *

Application Process

Your Information

Employer Information

Treatment Information

Personal Life

Legal Information

Final Questions!

Program Agreement

Program Guidelines