Transitional Living Communities
helping recovering substance abusers rebuild their lives since 1992
INFORMATION & APPLICATION FORM
Transitional Living Communities provides a safe recovery environment for clients who have a serious desire to stay clean and sober. Please initial in the space provided to the left of the statement.
Have you ever been arrested for a sex crime or arson? YES _____ NO _____
_____ New clients stay on property for 72 hours, and leave ONLY to attend 12-Step meetings WITH A SENIOR
CLIENT OF TLC.
_____ Restricted clients volunteer 4 hours daily to help upgrade and maintain TLC property.
_____ After 72 hours of restriction, clients enter "Entry Level". This allows the client to go to 12-step meetings,
seek work, or report to work, without support. "Entry Level" clients have a 10:00 p.m. curfew.
_____ After 15 days (and daily 12-step meetings), a client may apply for Level One - if the client has a sponsor, a
job, and is working a 12-Step program. Level One allows a client to leave the property alone, to support Entry Level clients and have a curfew of 11:00 p.m. weekdays and midnight on weekends.
_____ After 30 days as a Level One, clients may request Level Two, if they continue to meet Level One
requirements and service fees are CURRENT. Level II clients have a midnight curfew weekdays, 3:00 a.m. on weekends. In addition, a Level II may request overnight or weekend passes. No electronics are allowed until Level I. LEVEL TWO CLIENTS ASSUME ADDITIONAL RESPONSIBILITIES AS SENIOR CLIENTS OF TLC.
_____ TLC charges clients a weekly fee, in advance, for services it provides. Clients must report to the manager each Friday between 4:00 and 6:00 p.m., to pay for these services. TLC charges clients a notice fee if they leave without a week's notice, or before completing their commitment.
_____ Breakfast: 5 a.m. to 6 a.m. daily. Dinner: 5 p.m. to 6 p.m. daily. Lunch is available for self-preparation. Each client is assigned a daily chore and does dishes at least once a week.
______ Wake-up is at 6:00 a.m. weekdays and 7:00 a.m. weekends. Morning meditation is at 6:45 a.m. weekdays
and 7:45 a.m. on weekends. ATTENDANCE IS MANDATORY.
_____ Clients who are levels and employed may "sleep-in" one (1) day a week.
_____ Chores will be completed before leaving the property.
_____ Mandatory Peer Group Meetings are Tuesdays and Thursdays at 6:30 p.m.
_____ TLC offers an 8-week "Relapse Prevention" course on Sundays at 6:30 p.m. and a 12-week "Big Book Study" Wednesdays at 6:30 p.m. CLIENTS ARE REQUIRED TO ATTEND.
IMMEDIATE DISMISSAL OCCURS FOR THE FOLLOWING:
_____1. Use of drugs or alcohol on or off the property.
_____ 2. Not informing management when a client is using drugs or alcohol.
_____ 3. Violence or threats of violence.
_____ 4. Refusal to provide a urine sample.
_____ 5. Sex on the property.
_____ 6. A "chronic" bad attitude.
_____ 7. Not paying service fee.
_____ 8. Theft.
_____ 9. Arson.
_____10. Knowingly breaking any laws (local, state or federal)
TLC RULES WERE DEVELOPED AND ARE ENFORCED BY THE CLIENTS OF TLC. Management reserves the right to intercede any time it deems necessary to change or alter any decisions made by the clients.
I, ___________________________________________________desiring to become a client of TRANSITIONAL LIVING COMMUNITIES, understand these rules and regulations and will comply with them to the best of my ability.
SIGNATURE: ______________________________________________________DATE:__________
TRANSITIONAL LIVING COMMUNITIES
P.O. Box 1586, Mesa, Arizona 85211 (480) 833-0143 toll free (866) 646-2318
ENTRY QUESTIONAIRE
1. What is your secondary drug of choice? _________________________________________________________
2. How old were you when you first used / drank? ____________________________________________________
3. Have you ever been in Drug/Alcohol Treatment? ___________________________________________________
4. Have you ever been in a halfway house? _________________________________________________________
5. Number of year's school completed? _______ Graduate High School?_______ GED? ____________________
6. Have you ever been in prison? _____ How many times? ____________________________________________
7. Have you been in jail other than overnight? _____ If Yes: How many times? _______________________________
8. Have you ever been ARRESTED for a sex crime or arson? YES _____ NO _____ Convicted ________________
9. What state did you live in before moving here? ____________________________________________________
10. What kind of work do you do? ________________________________________________________________
11. What is your means of transportation? _________________________________________________________
12. What is your source of income? ______________________________________________________________
13. Check ONE: Are you Married _____ Single _____ Divorced _____ Separated _____
14. Have you ever had a DUI or DWI? Yes _____ No _____ If yes, how many?
15. What kind of problems has drinking and/or drugging caused you? _____________________________________
16. To what lengths are you willing to go to change? __________________________________________________
17. Do you have any problems with rules? _____ With authority? _____
18. Are you prejudiced towards any GROUP or RACE? _______________________________________________
19. Can we help you with any legal problems? _______________________________________________________
20. What kind of medical problems (physical or emotional) do we need to know about? _______________________
21. Have you ever considered suicide? No _____ Yes ______ If so, how long ago?
23. If yes, I agree to enter into a plan of action with staff ________________________________________________
24. What is your national origin? _________________________________________________________________
TRANSITIONAL LIVING COMMUNITIES
Intake Form
ID#________________ House:__________
Name: (PRINT) _______________________________________________________________________
Street: _______________________________¬¬¬_______ City: _______________________ State: ________
Zip: __________ S. S. #: _______ - _____ - _________ Birth Date: _____/_____/_____ Veteran? ______
Branch: ________________ Probation / Parole? ____________ Where? ___________________________
PO’s Name: ______________________________________________ PO’s Phone #: _________________
Drug(s) of Choice? _______________________________________ Last Use ?: ____________________
I’m taking the following medication(s):_______________________________________________________
______________________________________________________________________________________
Referred By: _________________________________________________ Entry Date: ________________
Lived at ANY TLC before? ______ When/Where? _____________________TLC Commitment: ________
CONDITIONS OF ENTRY: [ ] 90 meetings in 90 days [ ] Pay Service Fees Wkly [ ] ___ Day Entry
[ ] Big Book Study (12 wks) [ ] Relapse Group (8 wks) [ ] No new relationships for___ months
I will bring all of my uncashed paychecks to the TLC office. I will continue to bring them until my service fee balance is zero. The house manager will advise me when my balance is zero. I also agree that I will donate any change(less than $1.00) from my cashed check, to house funds._____
Other Conditions__________________________________________________________________________
________________________________________________________________________________________
BY MY SIGNATURE BELOW, I AGREE WITH THE ABOVE CONDITIONS:
SIGNATURE:______________________________________________DATE: ______________________
Interviewed By: (1)_________________________________ (2)___________________________________
(3)_____________________________
To submit this form fax to 480-833-4266 (Arizona) or 702-598-4867 (Nevada)
You can also mail it to Transitional Living Communities, P.O. Box 1586, Mesa AZ 85211.