Rapid Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.What counties are you applying for? Prices are program fees per month for the respective counties.Pierce – $700.00King – $650.00Whatcom – $650.00Spokane – $550.00Yakima – $500.00Name *FirstLastDate of Birth:Are you a veteran?YesNoAre you currently on DOC supervision?YesNoLayoutHave you ever applied to HOM in the past?*YesNoDOC #:Primary Phone Number:Either self or family memberIf yes, when? Include month and year.SSN:Primary Email:Either self or family memberSection A: Currently Incarcerated If the applicant is not currently incarcerated, feel free to advance to Section B.Layout (copy)Counselor Name:Eligible for DOC Voucher Program?Yes*NoInstitution Name:*If not, explain how you intend to pay program fees.Max Date:ERD:Section B: Not Currently IncarceratedThis applies to the applicants who are not currently incarcerated, even if you have previous felony convictions.Relationship with the applicantDepartment of CorrectionsCase WorkerAttorneyFamilyOtherComplete if someone other than the applicant is filling out this application.Current living situationGive a brief explanation of your current living conditions, whether it be homelessness, living with a friend, out of your car or otherwise. Please include the city you reside in.If accepted, what is your ideal move in date?Section C: Criminal and Health HistoryList the current charges first and then any previous criminal history:Please complete the application to the best of your abilities and be thorough and honest. Please note, we are looking for an honest and complete disclosure of all criminal history. Your criminal history will not cause you to be denied, however withholding information will be grounds for denial of application.LayoutSecurity Threat GroupYesNo(STG, or Gang Affiliations)Do you have medical conditions?*YesNo*If yes, please describe: Do you have any history of mental illness?*YesNo*If yes, please describe: Are you currently under the care of a mental health counselor or therapist?*YesNoIf in counseling or therapy, please briefly explain why.Have you ever abused drugs or alcohol?*YesNo*If yes, please describe: Prior substance use disorder treatment?*YesNoList all prescribed medication and the reason for those medications.ISRB: (Intermediate Sentencing Review Board )YesNoSex Offender Level (if applicable)123TBD/UnknownStipulated Agreement: Please read and check off each of the following stipulations as an indication of agreement. If accepted in the program, you will be expected to sign a document similar to this. *I understand I may be moved to a different house within the clean and sober program at the discretion of the Ministry Staff.I understand my clean and sober housing is contingent upon my active participation and compliance to all program stipulations contained herein and that Landlord/Tenant rights do not apply. I understand if I self-terminate or am terminated there will be no refund of Clean & Sober Housing Program Fees and I must leave the premises immediately upon request.I understand I may be terminated immediately for NON-PAYMENT AND/OR LATE PAYMENT OF PROGRAM FEES, INSUBORDINATION, A THREAT OF VIOLENCE, POSSESSION OF WEAPONS, PROPERTY ABUSE, LYING, STEALING, PORNOGRAPHY, OR BEING INVOLVED WITH ANY ILLEGAL ACTIVITY.I understand if I self-terminate or am terminated, I must take all my belongings with me. Anything left becomes the property of House of Mercy and may be immediately disposed of unless otherwise agreed upon — in writing – by leadership.Under no circumstance are non-prescribed drugs, alcohol or THC to be on the premises, possessed or consumed. The House Leader is to be informed of all prescribed drugs. Under no circumstances am I to give and/or share any prescribed drugs. Arrangements for possession and distribution are to be made with the House Leader. We do not accept anyone who is actively on opioid treatment i.e., MAT Program, Suboxone, Methadone, and Buprenorphine or any other similar narcotic-based drug.Applicants must be clean/sober for a minimum of 30 days prior to acceptance.You will be expected to participate in urinalysis and/or breathalyzer tests, at the discretion of leadership. Failure to participate upon request may result in immediate termination from the program. Any indication of drug/alcohol use while in the program could result in termination from the program.Overnight stays must be approved by the House Leader. A minimum of 48 hours advanced notice is required.No unapproved guests are permitted on the premises. I will seek approval from the House Leader prior to inviting guests onto the premises.I understand that pets are not allowed; this includes service animals.I understand I will participate in the chores of the home I occupy and I will maintain neat, sanitary living conditions. If there is more than one occupant, all must share equally in maintaining these conditions. Cleaning responsibilities will be assigned to each participant by my house manager and the leadership or staff will make inspections to maintain the standards House of Mercy has established.I agree to maintain healthy hygiene practices to include regular shower, shaving and dental hygiene.I understand initial curfew will be 8:00 PM upon arrival and will be changed to 11:00 PM if compliant within 7 to 10 days, unless adjusted by the resident house leader or staff.I agree to participate in all required program meetings. Any request to miss a required meeting must be approved in advance, by the house leader.I grant permission for program/treatment provider/employer to release any & all records, to be reviewed by the HOM leadership; to include, but not limited to mental health/therapy reports, financial & employer performance reports.I authorize the ministry leadership to confer with my employer, and/or any other treatment provider(s).I agree not to hold House of Mercy responsible for any injury occurring on or off properties owned, maintained, used, or leased by House of Mercy.I understand that all internet capable devices are to be utilized only by the owner and that they are not to be sold, traded, borrowed, bartered, shared, loaned or accessed by any HOM client other than the owner of the device.I agree to give House of Mercy leadership a 30-day written notice of my intent to move prior to vacating. In the event that I move prior to the 30 days, or fail to give notice, I will be responsible for the current month’s program fees, if not paid, and will forfeit any paid program fees.A one-month deposit plus a $125 non-refundable administration fee is required upon acceptance to reserve bed space. The deposit transfers to the first month’s program fee when the applicant moves in. If the bed is reserved and the applicant chooses to terminate this agreement for any reason the deposit is non-refundable.All Program Fees are due on the 1st of each month for the current month. The House of Mercy is a non profit organization and is dependent upon the payment of program fees by the client; any delays or non-payment of fees poses substantial burden upon the program, therefore, past due accounts for non-payment may be asked to relinquish their place in the residence to make room for a new client. Any payment received after the 5th of the current month is past due and a $25 late fee will be applied, and your program residency may be terminated.I understand that if I’m put on a payment plan or get behind on my program fees, I am required to take the Financial Freedom classes.I acknowledge that these guidelines have been read and/or explained to me. I agree that a signed copy of these conditions will be required upon acceptance into this program.I understand that I am responsible for complying with these stipulations and any others that might be added while I am involved with the House of Mercy Clean and Sober Program.I understand if I have an unpaid balance to HOM and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.In order for HOM or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that HOM and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. Furthermore, I consent the designated external collection agency to share personal contact and account related information with third party vendors to communicate account related information via telephone, text, e-mail, and mail notification.Please read and check off each of the following stipulations as an indication of agreement. If accepted in the program, you will be expected to sign a document similar to this. Date / TimeDateTimeSignature – By typing your name here you are agreeing to the above listed stipulations that you have checked off and affirming that all the information you entered above is correct to the best of your knowledge. *Submit
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