Application

THE NUMBER ONE REQUIREMENT IS A CLEAN DRUG AND 80-HOUR ALCOHOL SCREEN UPON ARRIVAL. PAST RESIDENTS WHO HAVE RESIDED LOCALLY AFTER DISCHARGE ARE INELIGIBLE TO RETURN

First Name *

Middle Name

Last Name *

Please provide an Emergency contact (required) *

Phone *

We are here to save lives, not assist with a legal defense in upcoming court cases or provide stable housing to comply with a court order. BHR CANNOT directly assist with your court case, transport you to court appearances or monitor your progress on behalf of court officials. We cannot accept anyone with an upcoming court date in the next 90 days.

COSTS INVOLVED:
PHASE 1 (28 days) = $875
PHASE 2 $150/Weekly
PHASE 3 $125/Weekly

ALL JOBS ARE ARRANGED AT SUPPORTIVE LOCAL BUSINESSES WITHIN SAFE WALKING DISTANCE WITH OTHER RESIDENTS. You will receive a fair wage to support yourself and rebuild your life. Working alongside others in recovery at a partner business is part of our program it is NOT optional. If you are restricted from working full time you will not be accepted. EBT nutrition cards are not permitted on our campus because we are self-supporting individuals that receive fair wages. By submitting this application you agree not to enroll in school during your residency.

Please understand that while we provide low cost housing, WE CANNOT OFFER FREE SERVICES and will not process those applications. THIS IS NOT A SHELTER.

You must follow up your application by initiating a phone interview. The applicant needs to personally submit his own application and personally make the phone call to follow up on the status of that application; we will not discuss your case with your family or your attorney. This is not a “diversion” program and we do not provide legal assistance for incarcerated persons. We operate on a first come first basis and do not take reservations or “hold” beds.

Choose below: *Phase 1 Residency Only (28 days)Long Term 3 Phase Commitment

Requested date of arrival *

Payment arrangements must be confirmed in advance before a bed can be reserved. WE DO NOT ACCEPT INSURANCE OR ACCEPT IOU ARRANGEMENTS. All payments can be made upon arrival for admission. If you are being funded by an organization or relative please indicate that below. After acceptance, study the web page called “pre-arrival checklist” to become prepared. Explain your funding for the $875 admission cost here:

In a few sentences explain why you should be considered for admission? Please explain.

RESIDENTS ARE NOT PERMITTED TO LEAVE for outside obligations or commitments during the initial 12 week period. Not for court or any other reason. Residents are not permitted to date while enrolled. Are you aware of any outside complications (business,
romantic or personal commitments, doctor appointments or hearings, psychiatric or medical appointments) that may interfere with your ability to fully participate in your first six – eight weeks of residency? Please explain.

SUBSTANCE INFORMATION *

Have you ever had an overdose?YESNO

Are you fully detoxed from all substances? (CAUTION: YOU WILL BE TURNED AWAY IF YOU CANNOT PASS A DRUG AND 80 HOUR ALCOHOL SCREENING)YESNO

Beach House Recovery is not a healthcare facility, therefore every resident must be successfully detoxed before admission to the program and test clean upon arrival. IF YOU REQUIRE A VISIT TO THE EMERGENCY ROOM FOLLOWING ARRIVAL YOU WILL BE DISCHARGED AND SUBJECT TO READMISSION. We may not allow ANY medication which has the potential to be abused. We do not allow herbal supplements. Every prospective resident is asked to submit to a drug and alcohol test immediately prior to their admission and will be turned away if positive.

HEALTH INFORMATION

WE MAY NOT ALLOW commonly abused sleep medications, WE MAY NOT ALLOW commonly abused mood stabilizers and WE MAY NOT ALLOW commonly abused depression pills. If the medication alters your mood or your mind in high dosage we will weigh the risks and may potentially deny IT.

Are you currently suffering from a chronic illness?YESNO

Do you require frequent doctor visits?YESNO

Do you have any mental health conditions?YESNO

Prescribed medications?YESNO

Physically willing and able to work?YESNO

Upon entering phase 2 everyone must maintain full time employment and accept any local position available. We DO NOT allow local residents to maintain the current employer associated with their addiction. If you are opposed to accepting an entry level job you will not be a good fit. Explain your job skills and experience in the section below:

Any physical limitations?YESNO

Beach House Recovery is not a medical facility and does not employ a medical staff or dispense medication. This means that you may not be accepted as a resident if you are not healthy enough to participate in all aspects of the program or require regular doctor visits. Participants travel frequently and no one is left behind due to poor health. This is not an appropriate facility for those with a serious mental health condition which requires medical monitoring.

EDUCATION

Can you read?YESNO

Can you write?YESNO

On probation?YESNO

Residents participate in functions that are sometimes outside of NC. You cannot be accepted if you cannot leave the state. It is your responsibility to make arrangements with your probation officer prior to admission.

Can you legally leave state?YESNO

Pending court dates?YESNO

Are you a sex offender?YESNO

Do you have a valid ID in your possession?YESNO

YOU MAY NEVER BRING OR STORE A VEHICLE IN THE CALABASH AREA UPON ADMISSION. Do you have a valid driver's license?YESNO

A social security card is absolutely necessary to enter phase 2. Do you have a social security card in your possession ?YESNO

Please provide the last 4 digits of your social security number.

Are you a convicted felon?YESNO

FAMILY INFORMATION

Pay court ordered child support?YESNO

Please read the following statements carefully as they represent a digital contract. By clicking submit you are agreeing to our NO REFUND policy. These items must be agreed to in order to submit your application and again upon arrival. Your acceptance is contingent upon a negative drug screen upon arrival and any subsequent positive screen will result in immediate discharge. Overwhelming suspicion of abusing OTC untraceable substances will result in eviction. Due to the minimal cost we will not issue refunds under any circumstances. Residents are never guaranteed transition or advancement into subsequent stages of the program beyond phase one. All records are kept private and confidential.

I have carefully reviewed the guidelines, understand all policies and agree to the terms and conditions. I acknowledge that using or obtaining a mood or mind altering substance, prescribed or otherwise, will result in eviction. I understand that BHR is not responsible for lost, stolen or abandoned property and will not guarantee storage or investigate missing items. Your possessions are your responsibility at all times.

I acknowledge I’m a guest, not a tenant, of Beach House Recovery. I will not establish legal residency, enter into a lease agreement or be promised any goods or services. I have been specifically advised that this is not a detox facility and we do not offer medical care. I understand that we do not offer mental health services beyond the scope of addiction. As a visitor I am not entitled to an eviction notice or arbitration if discharged. This arrangement will never change and I agree to leave upon request.

WAIVER OF LIABILITY: I hereby assume all risk of injury or harm as a result of residency at Beach House Recovery and agree to release, indemnify, defend and forever discharge BHR from all liability, claims, demands, damages, costs, expenses, and causes of action due to death, injury, loss, or damage due to the undersigned.AGREEDISAGREE

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