Resident Information Name*
First
Middle
Last
Gender* Are you required to reside in a certain county?*
Address*
A completed Release of Information (ROI) document is required for new clients arriving to NorthStar Regional. Has this been completed?
Financial Information Are you capable of paying rent?* How will rent be paid?* Currently employed?* Capable of working / volunteering?* Housing Support Funding (HSF) Eligible* If HSF funded, have you completed our HS financial intake form?
Chemical Use History / Legal Involvement Can you pass a drug test today?* Have you ever been charged with a sex crime?* Have you ever been convicted of arson?* Check one:*
Physical & Mental Health Are you under a physician's care?* Are you under a psychologist's care?* Are you under a psychiatrist's care?* Are you under a therapist's care? Ever planned suicide?* Ever attempted suicide?*
Emergency Contact Address*
All lines must be initialed by the participant for application to be accepted.
By signing or typing your full name below you agree that all information provided is true and accurate to the best of your knowledge. You also agree that you have a clear understanding of each initialed box above. The undersigned understands and acknowledges that the above marked facility is an alcohol and drug free property managed by NorthStar Regional. The undersigned resides in the capacity of a participant sharing facility space and not as a tenant with rights or possession of space exclusively. Additionally, the participant understands that he/she waives any landlord/tenants' rights as outlined under Minnesota Chapters 504B.0001 - 5048.471 and may be discharged at any time for violation of this agreement. The undersigned is responsible for all residential fees during the course of participation.
The undersigned participant agrees to be a part of and abide by the policies and rules set by NorthStar Regional The undersigned agrees to vacate the shared accommodation when cardinal, listed rules are violated. The following program policies are to be observed by all participants. These policies have been set forth by NorthStar Regional to maintain a clean, safe, and healthy living environment for those in recovery and to those who are willing and ready to change their lives and transition back into society. Any infraction of these program policies could result in disciplinary action and automatic removal from the facility. The decision to remain a participant is based on each participant's behavior, and our goals are to help each participant attain their goal of self-sufficiency by staying clean and sober and to find employment.
1. Program Fee: The program fee is $1135 per month. Participants receive a prompt payment discount down to $625 per month if they pay the program fee by the 5th of the month. After the 5th, there is a late fee of $5 per day, until the 10th . Payment on the 10th or later is not discounted. If a participant moves from the facility under emergency circumstances, prepaid service fees remaining shall be refunded on a pro-rated basis. Any failure by participant to pay fees when due, or failure to comply with any other of the conditions of this agreement allows NorthStar Regional to immediately void this agreement. Any infraction of the program rules may result in the immediate termination of the program agreement and expulsion from the house, and forfeiture of any program fees.2. Standard Curfew: All participants who are working will be expected to return to the house by 11:30 p.m. Sunday Thursday and midnight Friday & Saturday. Participants need specific permission to leave any earlier than 5:00 am or work later than 12:00 a.m. Curfews are designed to help our participants change behaviors and learn new skills.3. New Arrival Curfew: All new participants will return to the house by 9:00 p.m. every day. Clients coming to sober housing from NorthStar Regional Residential or Lodging are exempt from this rule and will abide by the standard curfew, see Rule 2. New participants will abide by the Standard Curfew after initial 30-day probationary period. (no passes during probationary period).4. Medication: Our facilities do not dispense medication. Our policy prohibits taking mood-altering medications including but not limited to; scheduled drugs, controlled substances, or narcotic medications; however, we understand that circumstances may arise that require such medications. Should this occur, participants may be discharged with a full explanation to any supervisory agency. Any participant sharing or receiving medication will be terminated without question. All medications are subject to accountability check(s) by staff or resident managers. Participants that are found to be abusing medications such as, ingesting dosages other than what is written on the prescription label will be discharged. New prescribed medications must be disclosed to resident manager immediately.5. Drug and Alcohol Use: Participation is made available on the strict understanding that the house is to be, at all times, drug, and alcohol free. If a participant uses any illicit drug, consumes alcohol, or ingests prohibited prescription drugs, the participant will be discharged immediately from the program. In addition, guests or visitors of a participant who are under the influence of any type of mind-altering substances are not permitted, at any time, in the house or on the grounds. Protecting and/or knowing a fellow participant is drinking or using may be cause for immediate dismissal. Reporting all suspicions to resident assistant is an expectation of every participant. Clients can be asked to perform a drug screen/toxicology test or breathalyzed at any time for any reason.6. House Liability: NorthStar Regional is not liable for any personal property during or after the participant's discharge from the house. NorthStar Regional will dispose of all personal property 60 days after discharge. NorthStar Regional assumes no responsibility for the personal property of the participant.7. Payment Plans: Payment plans will be written for all participants that are $200.00 or more in arrears in program fees/rent. They will be written by the Housing Coordinator and client together. Once the participant agrees to plan and signs the document, the document will be enforced. Participants in careers will be required to provide all pay stubs from their employer.8. No loud music: Only headphone type radios allowed. Loud and excessive noise disturbs other participants and will not be tolerated. The TV I s will only be played at reasonable volume levels and violation of these rules will be considered disruptive behavior.9. Without director's written permission, no participant will: install paneling, flooring, built in decorations, partitions or railings. Drill or attach anything to the floors, walls, or ceiling of the house, bring in any dish washing, heating, ventilating, air conditioning units, or any water filled furniture. All personal property not belonging to NorthStar Regional is subject to insurance at participant's expense, hang any shades, blinds and/or window guards in or outside of the premises, Permit the accumulation of garbage or recycle in the facility or move any furniture unless for cleaning purposes.10. Visitation: No visitors are allowed, except for same sex sponsors/spiritual advisors. Opposite sex visitors and others are only allowed at the property if they are family members and for a maximum of one hour (subject to resident assistant approval). Supervised children are allowed on site for no more than 6 hours and may be asked to leave if there are reports disruption(s). Covid policies for visitation are under NorthStar Regional’s discretion.11. Intimidation and/or violence: Any open or subtle hints of intimidation, violence or profanity towards participants or staff are grounds for immediate termination.12. No smoking in the house: Smoking in designated areas only, must be 10 feet away from any structure.13. No sexual activity: Not on the property.14. Housekeeping: Each participant is responsible for washing dishes immediately after eating. Sleeping areas are to be clean at all times. Participants are responsible for cleaning all community living areas. Participant will keep the premises clean at all times, and upon termination will leave the premises in as good of a condition. All participants are assigned and will perform weekly house chores.15. Excessive Utilities: Be aware of abusing free utilities. Turn off all lights in rooms not being used. Washers and dryers are available for your use. NorthStar Regional will pay all water, gas, heat, light, local telephone service, cable, and power to the house. The last person out of each facility should turn off all lights. Participants are not allowed to have hot plates, heaters, air conditioners, microwaves, small appliances, or large appliances in participant rooms.16. Out of Bounds: Participants may not enter another person's room without permission. If there is a roommate in the room, the guest wanting to enter the participant's room must obtain permission from the other roommate as well.17. No Food Areas: Food will be eaten in the dining and upstairs living area only. No food in bedrooms.18. Passes: Each participant has access to 5 passes per month. If client is from outside the NorthStar Regional system, a minimum of thirty days in the house is required. Participants are required to fill out a pass request form with a minimum of 48 hours' notice. The resident assistant will approve all passes based on performance in the house. All program fees must be current to be approved. Pass requests exceeding 5 days per month need to be approved in staff meeting.19. Work: Within 30 days, all participants are required to volunteer, be enrolled in, and attending school, or work at least 20 hours per week.20. Sleeping: All participants must be awake, dressed, with areas cleaned by 9:00 am on weekdays. Participants will not sleep in the living room. Lights should be out by midnight on weeknights.21. House Activities: All participants will participate in any house activities, including business meetings, group sessions, and weekly housekeeping duties. Additional activities, such as speaker meetings, occupational groups and/or housing network meetings. Mandatory workdays for all participants may be assigned for cleaning duties each month if the house becomes unsanitary.22. Mandatory House Meeting Attendance: All participants must attend weekly house meetings. This is an important meeting for all participants to attend, unless prior arrangement with staff has been made. If participants are unable to attend, they must leave their AA/NA meeting attendance card at the house, be caught up on rent, and call to check in with the housing coordinator within 24 hours of the house meeting.23. Sober Support Meeting Attendance: All participants must attend three outside published 12 step meetings per week. The meeting attendance slips are to be turned in to the resident assistant prior to weekly house meetings.24. Loitering: Loitering in cars by visitors and/or residents outside the facility is not permitted at any time and could be construed as mischievous behavior resulting in discharge.25. Sponsorship: All participants will be required to obtain a 12-step sponsor/mentor within 14 days of program participation. We will verify with your sponsor.26. Outpatient Treatment Programs: All participants must attend all court, parole/probation, social services referred treatment plans. Furthermore, clients must follow all discharge recommendations from their treatment programs. NorthStar Regional may request that participants provide discharge/assessment documentation. Clients enrolled in Outpatient Programs must attend all groups.27. Dress Code: All participants must be properly attired in the community areas.28. Pornography: No pornography and sexual aides in the facility.29. No pets: Participants are not permitted to have any pets on the property.30. Telephones: NorthStar Regional provides free in-house telephone service. Participants are allowed 10 minutes maximum for each call. Telephone service is a privilege. Any problems with the telephones will result in service being discontinued.31. Weapons: No weapons of any kind are allowed on facility property.32. Fraternizing: Any participant actively enrolled in treatment with NorthStar Regional is prohibited from fraternizing with other active clients. Doing so would risk discharge from both programming and housing.33. Notice to vacate: A written thirty (30) day notice of intention to discontinue participation is requested from all participants.34. Grievance: If a participant feels that another participant is not doing their share of the chores, or has any other grievances towards another participant, they may call a meeting with the resident assistant with all participants to discuss the grievance. If a participant’s action or behavior is found unsatisfactory by a majority of the participants at such meeting, the participant will be given the opportunity and reasonable time to change their behavior. If, after two such meetings, the offending participant fails to make the necessary changes, the director will be advised, and subject to his discretion, may terminate the program agreement. Complaints; ombudsman for mental health and developmental disabilities. Any complaints about a sober home may be made to and reviewed or investigated by the ombudsman for mental health and development disabilities, pursuant to sections 245.91 and 245.94 Subd.4. 35. Vehicles: To operate and/or park a motor vehicle while residing at the facility, a valid driver's license, proof of insurance and registration are required. Copies need to be in file at the main office. The vehicle may be towed at your expense. If you own a vehicle and can't legally drive it, park it elsewhere.36. Room inspections: Room inspections may be carried out at any time by the Resident Assistant, which is subject to approval of the Housing Coordinator or other staff. Staff may search participant rooms at any time.37. Theft: Any instances of stealing will result in immediate expulsion and be forwarded to police who will make a decision on charges and prosecution. This includes stealing from other peers, taking items from the house/property. i.e. pillows and linens, that are not yours, and taking food with you that is not yours. Participants being funded by the Housing Support Fund (formerly known as GRH) are not authorized to take any food with them when they leave.38. Bar/Casino Restriction: Clients are not allowed to go to casinos at any time or for any reason. Clients are not allowed to go to a bar unless it is also an eating establishment, and they are there to eat a meal.39. Length of Stay: The Maximum length of stay is 9 months. Exceptions made for Resident Assistants. 40. Reporting Income: If a client is being funded by the Housing Support Fund, and you are working, said client has 10 days from the day of receiving income by law to report any income to their financial worker at the county. This pertains to people working for cash or check, as well as people receiving a paycheck from a company. If the client does not report their income, they are subject to discharge and staff will report them to their financial worker.41. Transportation: Clients must use med rides from insurance for transportation to and from programming. If ineligible, NorthStar Regional will provide transportation to and from programming only. Clients must call 24 hours in advance to request a ride from NorthStar Regional. If you don’t need the ride, you’ve already scheduled, call and cancel immediately. Failure to follow transportation expectations may result in loss of transportation privilege.42. Consequences: The staff of NorthStar Regional reserves the right to enforce the following consequences for infractions of any, or all, of the above house policies. The consequences may include extra chores, behavioral contract, restriction to the house, no passes, or discharge from the program.
Bill of Rights An individual living in a sober home has the right to:
Private Right of Action In addition to pursuing other remedies, an individual may bring an action to recover damages caused by a violation of this section.
Please type or print the following: I HAVE READ AND UNDERSTAND HOUSE POLICIES AND PROGRAM AGREEMENT:
By signing or typing your full name below and the last four digits of your Social Security Number, you agree that all information provided is true and accurate to the best of your knowledge. In addition, you agree you understand and will abide by all program policies and may be subject to program discharge for violation of any program policies.
Please note: Incomplete applications will not be considered. In addition, to be placed on waiting lists, a complete program application must be submitted.
