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Part 1 of the Victoria House Residency Application.

Part 1 of the Victoria House Residency Application.

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  • 1. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 1 VICTORIAN PROPERTIES LLC®2009. AZ, USA. Victoria House Application Part 1 of 2. Prospective Resident Details, Application/Resident Status Update. Robert E. Widing III Part 1 of 2 Drafted on 10/01/08 Revised on 05/17/09 Revised on 06/26/09 Revised on 11/19/09 This document provides no guarantees, commitments or responsibilities, remains the property of, and is subject to approval by; shareholding member/s, company officer/s and/or the Authorized /Responsible Agent/Representative of Victorian Properties LLC® to act on behalf of the company. Authorization/s and/or appointments to act on behalf of the company and/or its subsidiary; Victoria House in the Commonwealth of Pennsylvania are subject to the LLC' Operational Agreements and the laws of its Jurisdiction. Agreement/s are; subject to Approval, non-binding, sever- able and may change until consideration is exchanged. Victorian Properties LLC® is an Arizona based Limited Liability Company and reserves all rights afforded under Federal, State, Commonwealth and Provincial Authorities including but not limited to the right/s of; Limited Liability, Civil and/or Criminal Restitution, Lien and Rights given under applicable Landlord Tenant Acts or Laws in/lieu of a Governing Act via; Statute, Tort, Judgment or other Legal APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 2. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 2 Remedies. Agreements with Victorian Properties LLC® are subject to the Laws of its State of Incorporation and/or operation. Agreements under the LLC' stamp/seal supersede that of any regional law/s with the exception of Applicable Federal Statutes that may be proven via; Hearing, Trial or Judgement set by Governing Courts of; District (Magisterial), County, District (Appeals Circuit), State and/or the Supreme Court of the United States of America in Constitutional and/or Amendments therein, to Uphold the Law of the Land. APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 3. APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA VICTORIA HOUSE. 1156 W. 11TH STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 4. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 1 DBA VICTORIA HOUSE 1.a) Current Living Arrangements & Related Full Name: ____________________________________________________________________ Current Residents: Tick NO for the next 2 Questions. Are you coming from a Rehabilitation or Treatment center? YES_____ NO_____ Are you coming from a Halfway/Group House or Similar? YES_____ NO_____ If you answered YES to either question, please write down the name of center, institute or house including the type of service they provide, ie; drug/alcohol rehabilitation, counseling (types) etc. * If NO, skip to 1.b) Address and write your current mailing address or primary residency. Current AND Prospective Residents: If you have a TCM Please use as your Reference. Facility (Examples; Salvation Army Rehabilitation Center, Snow House or Maria House Projects): Facility: _____________________________________ Length of Stay: ____________________ Purpose of Stay: ________________________________________________________________ Discharge Date: ______/______/______ OR Lease/Contract End Date: ______/_______/______ Reference (Counselor, Psychiatrist, Employer, House Manager, Center Coordinator, Therapist etc.) Reference Name: _________________________________ Position: ______________________ Work# __________________ Mobile# ___________________ Other# ____________________ 1.b) Current Address and Contact Information Address: ____________________________________________________________________ ____________________________________________________________________ Phone: H: ____________________ M: _____________________W: ___________________ Other: _______________ E-mail: __________________________________________ N/O/K: Name: ___________________________________ Relation: ____________________ Phone: Home: _________________________ Mobile: _______________________________ APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 5. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 2 NOTE: Next of Kin MUST BE CONTACTABLE. Write 2 CURRENT phone numbers 2.a) Criminal History Information (Current Residents: List any Changes if any) Please answer HONESTLY. Falsifying information may have serious legal consequences. 1. Do you have a criminal history? YES______ NO______ 2. If YES, is it a Felony? YES______ NO______ 3. Are you on Probation or Parole? YES______ Fill (a1) NO_____ Skip (a1) (a1) If YES to last question, please provide: Type of paper are you on? P/O or Agents Name, Contact Number w/ext? Duration? ANY and ALL Conditions of Parole? Current Residents: Treat as new application noting everything Before AND During stay: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (a2) If YES to either questions, please BRIEFLY, describe the charge/s. Do not put down any unresolved or non-disclosed information that may put you at risk of further prosecution. Please write down only what you have been convicted of, have satisfied judicial punishment for and are absolved of or still involved in the reparations process; State Parole, County Probation etc. *If this section is not applicable, please write a large N/A. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2.b) Outstanding Legal or Related Issues (b1)If you have any outstanding legal issues such as court appearances, mandatory drug or alcohol tests, probation officer visits, mandatory counseling etc. Please write them down. This is not to be intrusive but Victoria House Management must know if there are to be unexpected visits or issues from legal or Law Enforcement Authorities. *If this section is not applicable, please write a large N/A. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 6. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 3 3) Employment and Financial Viability. This section is to establish how you are planning to support yourself. Please only fill out what is applicable to you. You will not be judged, marked or attain any advantage in this section as its only aim is to establish if you will be able to afford to live at Victoria House. For example, if you do not plan on working due to disability, or are unemployed and family are going to help pay rent until employment or studies are started, list it. Employment or Employable Are you working or have a confirmed future job? YES_________ NO_________ If YES, Please list your job and or upcoming job, including the name of the business, location details and the contact number of the business and/or a supervisor/manager. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If NO, are you going to be looking for work? YES_________ NO_________ If YES or NO, briefly explain how you are going to be able manage financial obligations on an ongoing and sustainable basis. Also, If NO, write how you are going to better self/community? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Government sponsored Disability Payments Are you currently on a government subsidy or disability? YES_________ NO_________ If YES, will you be on this payment for 3 months or more? YES_________ NO_________ What is the name of this benefit/s? _________________________________________________ CASH ($) and/or FOOD STAMP (FS$) Entitlements: $______._______pm FS$____________ If NO, will you be able to find alternate income sources? YES_________ NO_________ DO YOU BELIEVE THAT YOU WILL BE ABLE TO MEET THE FINANCIAL OBLIGATIONS NEEDED TO LIVE AT VICTORIA HOUSE? APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 7. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 4 YES________ NO________ 4.a) Alcohol and Drug Information Victoria House is a recovery house for those recovering from drug/alcohol affliction. This section assumes a lot and therefore it is up to the individual as to how in depth he answers. Are you primarily an: ________ Alcoholic ________Drug Addict ________Duel Diagnosed ________All of the above What is your Drug of Choice (If primarily Alcoholic, put Alcohol)? _______________________ Current Residents: Treat as a new application. Note any Relapse/Incident/Hospitalization etc. What other drug or drugs (if any) have you had a problem/s with (including prescription meds)? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you completed or been in a 28+ day inpatient OR outpatient program? YES____ NO_____ Do you have OR require a continuation of care or follow a treatment plan? YES ____ NO ____ 4.b) Other Related Information Current Residents: Include ANY Changes: How long have you been clean from your primary DOC? _______________________________ How long have you been completely clean of all drugs/alcohol including prescription medication that is/was; not prescribed, not taken as prescribed, abused and/or not under medical supervision with regular consultations from a Doctor or Psychiatrist for psychotropic/scheduled medications? AND How long you have been clean of your Drug of Choice as well as any other drugs that you should not have taken? How long have you been a "responsible" clean person in recovery? And briefly detail your last relapse/hospitalization/arrest; informing; what drug/s, type/s of alcohol, why etc. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 8. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 5 5.a) Voluntary Medical Disclosure This section like all others is kept with complete confidentiality. The purpose of this section is to help safeguard you as an individual from theft, false accusations and any other mishaps regarding prescription medication. Furthermore this will help to provide understanding of any conditions you may have. NOTHING in this section will influence your decision on admittance. Victoria House allows admittance based on the character of the individual NOT medical conditions. This question is COMPLETELY optional Do you have any medical conditions that you wish to notify Management about should you so provisions may be made to save you embarrassment, harassment or unnecessary bad feelings? This applies for any condition and Management can provide; extra privacy, extra sheets, lifts for preventative treatments of chronic life threatening conditions (may require documentation), additional disinfectants/detergents, better security, more separated food storage options etc. YES_______ NO_______ 5.b) Mandatory Medical Information Are you on any prescription medications? YES_______ NO________ If yes, Please list the medications you are taking. Please note: You are responsible for your own medications. Management will not hold, dispense or place in security any of your medications. The security and management of your medications are your own responsibility; however, you MUST detail what you are on, keep your medications in labeled prescription containers, take as prescribed and notify Management of any changes including the collection of medication from a new or different doctor than that of your other medications. Please understand, this is for your protection, in the case of stolen/missing meds, the usage of non prescribed medications or the possession of non prescribed medications may result in your contract termination. In some cases police involvement may be necessary. When multiple parties are involved, whoever is most upfront and honest typically gets the benefit of doubt. Medication/s: Current Residents: List Meds W/Dosage. Write Down ANY Changes in the Last 3 Months: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are any of these medications Scheduled (schedule 1, 2, 3, 4 or 5) or listed under the Federal Controlled Substance Act (Body corporate will terminate residency if not informed)? Yes_______ NO_______ APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 9. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 6 If yes, list the medication/s in the above section. A YES answer is OK if DR. PRESCRIBED and monitored. If so it’s recommended you purchase a lock box for security (can easily be arranged). 6) Individual Considerations, Conditions, issues or Agreements PLEASE COMPLETE Q1 and Q2 WITHOUT HOUSE MANAGER PRESENT Q1) Applicant and/or Resident have and agreed/disagreed to address the following (Any Issues): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Q2) I have the following Concerns and/or feel these Suggestions or Changes are worth mentioning: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Q3) This brought us both to the following conclusion/s: COMPLETE WITH MANAGER: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ COMPLETED: APPLICANT (X) __________________________________ DATE ______/______/______ MANAGER (X) __________________________________ DATE _____/______/_______ END PART 1 STAMP OR SEAL AUTHORIZED REPRESENTATIVE (PA) ROBERT E. WIDING III INTERNAL USE COMP: _______/______/______ APP/DEC__________________ DT______/_______/_______ APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391
  • 10. VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 7 ASST: ______/_______/______ P2RA _____/______/_____ P2-SP Y____ N ____ C_____ APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s DBA TH VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391