Mission Unity Recovery House
Name: ________________________________________ Date: _______________________
Provide the date and type of last substance abuse or use of any kind. Include any and all illegal, legal,
prescription or non-prescription drugs including those regularly taken and prescribed under a doctor's
care. ALCOHOL is a DRUG and must be included on the list
Substance Last Used
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Signature: ______________________________ Date: _____________________
Name: ________________________________________ Date: _______________________
Provide the date and type of last substance abuse or use of any kind. Include any and all illegal, legal,
prescription or non-prescription drugs including those regularly taken and prescribed under a doctor's
care. ALCOHOL is a DRUG and must be included on the list
Substance Last Used
_______________________________ _________________________________
_______________________________ _________________________________
_______________________________ _________________________________
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Signature: ______________________________ Date: _____________________
MY AGREEMENT
As a resident of Mission Unity Recovery House, I am willing to take the suggestions that have been
outlined before me. It has been proven time and again that there is no quick fix to the disease of
alcoholism and addiction.
* It is suggested that I remain in the Recovery House for a period of at least 90 days.
* It is suggested that I attend a 12 step recovery program meeting on a daily basis.
* It is suggested that I get a sponsor and work the 12 steps with that sponsor.
* It is suggested that I become involved in service to others, both in the Recovery House and in my 12
step program.
Even though I may not fully understand how these simple suggestions may bring about a life altering
experience, I am willing to commit myself to these suggestions to the best of my ability.
NAME:_________________________________________________
DATE: _________________________________________________
Intake Form (Rev 4/10/2009)
1. Name _______________________________ Birth Date ___________________
2. SS# ___________________________ Ethnicity _________ Hispanic _______
3. Arrival Date ________________ Gender _________ Pregnant ___________
4. Marital Status _____________ Referral _______________________________
5. Emergency Contact Name __________________________________________
County____________________ State ______________
6. Relation _________________ Phone # _________________________________
7. Do you have any children? _______ Who has custody? _______________
8. Are you employed? _______ Do you have any other income? _________
9. Are you a veteran? _______ What type of discharge? _________________
10. Do you receive benefits? ___________________________________________
11. Are you a resident of Charlotte County? _______ How long? __________
12. Are you homeless? ________ How many times? ______________________
13. Were you institutionalized prior to 18 yrs. of age? ___________________
14. Do you have any disabilities? ______________________________________
15. Any infectious diseases? __________________________________________
16. What is your level of education? ____________________________________
17. Do you have a drivers license? _______ Transportation? _____________
18. Are you a U.S. citizen? ______ Have you tried AA before? ____________
19. Do you have a relative, spouse or friend residing with Mission Unity,
Inc. (Past or Present?) ______________________________________________
Resident Signature:__________________________________________________Date:__________________
1. Name _______________________________ Birth Date ___________________
2. SS# ___________________________ Ethnicity _________ Hispanic _______
3. Arrival Date ________________ Gender _________ Pregnant ___________
4. Marital Status _____________ Referral _______________________________
5. Emergency Contact Name __________________________________________
County____________________ State ______________
6. Relation _________________ Phone # _________________________________
7. Do you have any children? _______ Who has custody? _______________
8. Are you employed? _______ Do you have any other income? _________
9. Are you a veteran? _______ What type of discharge? _________________
10. Do you receive benefits? ___________________________________________
11. Are you a resident of Charlotte County? _______ How long? __________
12. Are you homeless? ________ How many times? ______________________
13. Were you institutionalized prior to 18 yrs. of age? ___________________
14. Do you have any disabilities? ______________________________________
15. Any infectious diseases? __________________________________________
16. What is your level of education? ____________________________________
17. Do you have a drivers license? _______ Transportation? _____________
18. Are you a U.S. citizen? ______ Have you tried AA before? ____________
19. Do you have a relative, spouse or friend residing with Mission Unity,
Inc. (Past or Present?) ______________________________________________
Resident Signature:__________________________________________________Date:__________________
MISSION UNITY INC. RECOVERY HOUSE
RESIDENT FEE POLICY
REVISED 9/22/06
INTAKE FEE: $50.00 one time, non-refundable.
WEEKLY FEE: $150.00 per Week.
DAILY FEE: $20.00 per Day
Fee's are determined on a case by case as needed basis.
FEE INCLUDES: Housing with all utilities, local phone service, coin operated laundry facilities and food
for lunch and dinner.
Transportation will be provided to AA Meetings held at the ‘Daily Reprieve Club’.
Rides to job interviews and essential appointments can be arranged with prior notice.
Fees are based on a full-time, minimum wage salary. If a resident is unable to pay any amount of fees
upon entering Mission Unity, Inc. Recovery House, arrangements can be made with the agreement
that each party abides. RECEIPTS WILL ALWAYS BE PROVIDED.
If a resident is asked to take a drug screen or alcohol breath test, there will be no cost to the
resident. However, if the resident requests a 2nd test, a $20.00 fee will be applied.
Resident Signature:__________________________________________________Date:__________________
I have read and understand the above policies and intend to comply
RESIDENT FEE POLICY
REVISED 9/22/06
INTAKE FEE: $50.00 one time, non-refundable.
WEEKLY FEE: $150.00 per Week.
DAILY FEE: $20.00 per Day
Fee's are determined on a case by case as needed basis.
FEE INCLUDES: Housing with all utilities, local phone service, coin operated laundry facilities and food
for lunch and dinner.
Transportation will be provided to AA Meetings held at the ‘Daily Reprieve Club’.
Rides to job interviews and essential appointments can be arranged with prior notice.
Fees are based on a full-time, minimum wage salary. If a resident is unable to pay any amount of fees
upon entering Mission Unity, Inc. Recovery House, arrangements can be made with the agreement
that each party abides. RECEIPTS WILL ALWAYS BE PROVIDED.
If a resident is asked to take a drug screen or alcohol breath test, there will be no cost to the
resident. However, if the resident requests a 2nd test, a $20.00 fee will be applied.
Resident Signature:__________________________________________________Date:__________________
I have read and understand the above policies and intend to comply
HOUSE RULES POLICY
REVISED 4/25/2006
ANY VIOLATION OF THE FOLLOWING WILL RESULT IN A 30 MINUTE SUPERVISED EVICTION FROM
MISSION UNITY, INC. PROPERTY.
1. Zero tolerance for drug and/or alcohol use. We reserve the right to test randomly. If you test
positive you will have 30 supervised minutes to vacate Mission Unity, Inc. property. Refusal to test
will be treated as a positive result.
a) Refusal to vacate in allotted time will result in local law enforcement supervision.
2. No weapons or drug paraphernalia are permitted on premises. Or inside personal vehicles.
3. Violations of probation, house arrest, driver license suspension or DOC restrictions that apply to
you will not be allowed to occur on Mission Unity, Inc. property and will be reported to the proper
authorities.
4. Fighting, aggressive behavior, threats of violence, racial slurs, sexual harassment or any other
socially inappropriate behavior will not be tolerated.
a) Pornographic materials of any kind are not allowed on Mission Unity, Inc. property.
5. Any theft or vandalism of the house property or resident's personal property will not be tolerated.
a) Wall lockers, dresser drawers, and cubby's are considered personal space and are private to the
assigned resident and house management.
b) Includes resident's personal food, grocery and hygiene items.
6. Guests are allowed to visit for a period of 1 hour. All visitors must stay outside the house and
must leave by 10:00PM. Only residents and house management are allowed inside Mission Unity
property.
No one under the age of 18 is allowed on Mission Unity, Inc. property unless accompanied by their
parent at all times. Please see "HOUSE VISITATION POLICY" for further details.
7. Effective immediately (all new residents) no overnight passes for the first 30 days.
8. Local telephone service is provided for resident's use. The primary purpose of the telephone is
to enable residents to obtain employment, set up appointments with other helping agencies and to
obtain transportation.
a) Residents are expected to use the phone at their primary house, not other Mission Unity, Inc.
properties.
b) To respect other's privacy, the phone is to be answered "HELLO" "NOT MISSION UNITY"
c) If you answer the phone you are obligated to take a message. The phone is equipped will call
waiting. You are required to interrupt your call to answer. All messages must be written on the
message board. It is each resident's responsibility to check for his/her own messages.
d) Personal calls are allowed with a 10-minute time limit. With prior approval, exceptions may be
given for long distance calls.
e) No incoming calls after 10:30PM. No outgoing calls after 11:00PM. This includes personal cell
phones.
f) Cell phones are to be set on silent mode inside the house. All cell phone conversations are to
take place outside the house.
g) Remember that phone use is a privilege. Any attempt to use the phone illegally will result in
immediate dismissal and possible legal consequences.
9. Resident curfew is at 10:30PM, seven nights a week. Any interference with a housemate's ability
to sleep will Not be tolerated.
a) Lights, TV's and radios must be off by 12:00 midnight.
10. Cleaning and maintaining all common living areas including kitchen, bathrooms, laundry room,
and yard is everyone's responsibility. A chore list is posted in each house and is assigned by the
house manager.
a) Chores must be completed by 10:30PM each night.
b) No laundry is to be started after 10:00PM each night.
c) Personal dishes such as plates, cups, silverware, etc. must be cleaned and put away immediately
after . use. "Do not leave them in the drain to dry".
d) Personal toiletries such as towels, soap, shampoo, etc. must be stored in resident's personal
space after each use.
e) Personal sleeping space is your responsibility and must be maintained in an orderly fashion. Beds
are to be made every morning when you wake up.
11. Each resident is required to attend a 12-step recovery meeting of Alcoholics Anonymous or
Narcotics Anonymous 5 days a week.
a) See "SUGGESTIONS FOR RECOVERY" (Attached).
12. Smoking is not allowed inside the house.
a) Each house has a smoking area designated.
b) Ashtrays are to be used. Do Not Throw Butts On The Ground!
c) Redmond house residents do not use any doors at north end of house.
13. House meetings will be scheduled in advance and attendance is mandatory unless you are at
work.
14. There will be no women allowed in men's houses, and no men allowed in women's houses at any
time.
MISSION STATEMENT: The purpose of Mission Unity, Inc. Recovery House is to provide a safe, family
group living environment for men and women who are experiencing a transition into society while
recovering from substance abuse.
By living together in mutual respect, you will be part of a healing community that will assist you as
you strive to improve your life.
I have read and understand the above house rules and intend to comply. I understand that if I
choose to leave Mission Unity, Inc. as a result of the breach of any of these rules, any prepaid fees
for the week in which I am required to leave will be forfeited.
Resident Signature:_____________________________________
Date:___________________________________
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