ALICE’S
HOUSE
Women's Recovery Program
ADDRESS: 606 Brown St., Valparaiso, IN 46383
OFFICE: (219) 462 - 7600
FAX: (219) 462 - 7600
EMAIL: aliceshouse.valpo@gmail.com
WEBSITE: aliceshousevalpo.org
STEP #1:
PRELIMINARY QUESTIONNAIRE
FOR PROGRAM CONSIDERATION
DATE RECEIVED BY ALICE’S HOUSE: / /
REFERRED BY:
COUNSELOR:
OFFICE/WORK PHONE(S):
EMAIL:
APPLICANT’S INITIALS: AGE:
SOBER SINCE:
ALICE’S
HOUSE
Women's Recovery Program
APPLICANT
QUESTIONNAIRE
DATE: / /
NAME OF PERSON COMPLETING THIS FORM & RELATIONSHIP TO APPLICANT:
APPLICANT’S LEGAL NAME:
SHORTENED/NICKNAME: AGE:
CURRENT ADDRESS:
CITY: STATE: ZIP:
HOME PHONE: CELL/OTHER:
EMAIL:
DOB: / / SOC. SEC#:
EMERGENCY CONTACT NAME:
Relationship to you:
City/Town: Phone:
I, (your first name), agree to allow the House Committee of Alice's to discuss my background and treatment with other professionals and agencies. I understand for my protection and others there may be a need for the House Committee and the staff of Alice's to check on my legal standing. I also understand that I am giving permission for the House Committee and the staff of Alice's to contact any and/or all names and facilities on this application. I also agree to waive, release, and not to sue Alice's House. of Valparaiso, IN, its officers, or staff for any and all damages of any kind whatsoever suffered as a result of living at Alice's. Alice's House is not responsible for any losses, thefts, damages, or injuries incurred while living at Alice’s.
APPLICANT’S PRINTED NAME:
SIGNATURE: DATE: / /
This application is designed to help us understand how we can support you as an individual at Alice’s House.
Please use a separate sheet of paper when necessary to include all relevant information and attach)
PRESENT STATUS
What was happening that prompted you to seek treatment?
Whose idea was it to connect with Alice’s House?
Describe your emotional state & feelings about living at Alice’s?
What is your current living situation? (e.g., staying with family/friends, temporary shelter, your own place, etc.)
Describe your living situation of who you lived with and where, before seeking treatment help?
Are you responsible for taking care of anyone else or any pets? Yes ☐ No ☐ If yes, who & how old are they?
Where will you live if Alice’s House cannot accommodate you, what is your backup plan?
Are you part of any community or spiritual group? Yes ☐ No ☐ If yes, describe:
MARITAL STATUS
Married Divorced Widowed Never Married
How long have you been in this marital status?
Are you satisfied with this situation? Yes ☐ No ☐ In no, please explain:
Do you have any children? Yes ☐ No ☐ If yes, list below:
NAME AGE WHERE LIVING W/WHOM
How would you describe your relationship with your spouse and children (if applicable)?
ALICE’S
HOUSE
Women's Recovery Program
CULTURAL BACKGROUND
Where were you born?
Where did you grow up?
Who were you raised by?
Was religion part of your upbringing & what denomination if so?
Did you attend religious services and do you attend any now?
Do you still practice following that religion or has it changed?
Describe your family’s attitudes towards drinking & drug use?
FAMILY OF ORIGIN - Assessment
NAME AGE If deceased, age at death Your age at time of passing OCCUPATION
Mother
Father
Please describe your caregivers/parents and their relationship. If divorced, when?
Describe your relationship with your parents and or caregivers who raised you:
List any siblings (including deceased, step, foster):
NAME AGE SEX RELATIONSHIP/FEELINGS TOWARDS EACH OTHER
Did/do any of the above family members use alcohol or drugs? When and with what effect?
Do you feel accepted, loved, and cared for by your family of origin?
Who in particular were/are you close to?
Growing up, was their respect for family members’ privacy at home?
What activities did your family share/engage in together and or prioritize? (Describe in full)
Have you lost love or support due to your drinking or drug use at any time? (please describe)
ALICE’S
HOUSE
Women's Recovery Program
HEALTH & WELLBEING
Do you have any allergies or specific dietary needs? Yes ☐ No ☐ If yes, please tell us more:
To your knowledge, are you medically stable at this time? Yes ☐ No ☐ If no, please explain.
Are you independently capable of responding to a life threatening emergency? In not, please explain.
Do you have any physical health concerns or ongoing conditions that require special attention or care?
Yes ☐ No ☐ If yes, please explain:
Are you currently seeing a therapist, counselor, or any mental health professional? Yes ☐ No ☐
If yes, please share anything you’re comfortable with:
Have you been diagnosed with any mental health conditions? Yes ☐ No ☐ - If yes, please list:
Are you taking any medications? Yes ☐ No ☐ If yes, share the name, dosage, and frequency?
Have you been chemically free for 10 days? Yes ☐ No ☐ Sober Date:
Do you think of yourself as an alcoholic, addict, or both? What makes you think this, share your terms/definition:
NUTRITIONAL ASSESSMENT
Do you have hypoglycemia anorexia, bulimia and or sickle cell anemia? Please list:
Are you an over-eater? If so, how long is this been going on?
List your binge foods, if any:
Do you exercise? Yes ☐ No ☐ If yes: what do you engage in, where, and how often?
Do you have any limitations or physical needs that impact your ability to exercise? If yes, please explain:
ALICE’S
HOUSE
Women's Recovery Program
TREATMENT HISTORY
Medical/Psychiatric Hospitalization
FACILITY DATE DIAGNOSIS
Have you attempted suicide before? If yes, when:
Chemical Dependency Treatment (detox, in-patient, residential)
FACILITY DATE DIAGNOSIS
Outpatient Counseling (Social Work/Psychologist/Clergy)
FACILITY/COUNSELOR DATE DIAGNOSIS
List any facility that was a successful program for you:
Have you used chemicals, including alcohol, to overcome pain and or depression?
What are your got-to outlets for stress & frustration?
ALICE’S
HOUSE
Women's Recovery Program
VOCATIONAL HISTORY
Highest completed level of education:
Are you currently taking any classes or enrolled in any trainings? Yes ☐ No ☐ If yes, please list:
What is your usual occupation?
Are you currently employed? Yes ☐ No ☐ Occupation: How long?
Do you like your job/line of work? Yes ☐ No ☐ Do you get along with coworkers?
List any special training, skills, licenses, and or qualification:
List any Military Service:
Do you volunteer anywhere, formally or occasionally? Yes ☐ No ☐
- If yes, share a bit about your job? (Job title, where you work, hours, level of satisfaction)
If you’re not currently working or volunteering, please share if this is a personal choice or due to a barrier that prevents you from being able to work or volunteer:
List you employment history for the past 10 years
OCCUPATION COMPANY START & END DATE HOW LONG REASON FOR LEAVING
Please describe the effects of drinking and or drug use on your job:
ALICE’S
HOUSE
Women's Recovery Program
CHEMICAL HISTORY
ALCOHOL:
How old where are you when you had your first drink?
How old were you when you were first intoxicated?
How old were you when you thought you might have a problem?
Drink of preference & quantity? How often do you drink?
Where and when did you usually drink?
Did you drink alone? Yes ☐ No ☐ If yes, how often?
When and how long was your longest dry period?
When/how did you return to drinking?
Do you think you can control your drinking consistency?
When was your last drink?
When was your first contact with A.A.?
Have you taken the 4th & 5th Steps? Any others?
Describe your present A.A. involvement (meetings, sponsor, group, etc.):
DRUGS:
List, all drugs used:
Age of first drug use: Age when you thought you might have a drug problem?
Your preferred quantity & frequency of use?
Have you experienced any accidental or intentional overdoses? If so, when:
Your usual place or places of drug use:
Your longest period of time drug-free: Last date of drug use:
Have you ever gone to NA? If so, when:
ALICE’S
HOUSE
Women's Recovery Program
LEGAL
Please list any of the following and related information:
ARREST/LAWSUIT/DUI DATE STATUS
Were any of these drug and or alcohol related? Yes ☐ No ☐ Pending court cases? Explain either/both:
Do you have any other legal concerns or history that you’d like us to know about? Yes ☐ No ☐
If yes, please share what you find important for us to know, sharing this helps us better understand to better help.
FINANCIAL STATUS
Your source(s) of income and amount of income:
Are you in debt? Yes ☐ No ☐ If yes, how much?
To whom?
List your financial problem areas (behind in payments, bankruptcy, other):
Please estimate the total amount of money spent on alcohol & drugs? $
Alcohol: $ Drugs: $
Estimate the total amount spent on the consequences of alcohol and drug use in only the past 2 years: $
ALICE’S
HOUSE
Women's Recovery Program
YOUR INTERESTS & GOALS
What about Alice’s House inspired you to apply?
What specific life challenges would you like help with while at Alice’s?
Describe any Long-Term goals you may have:
What would you like to achieve during your time with us? (For example, maintaining sobriety, finding stable work, focusing on your health, etc.)
How do you think Alice's House can support you in reaching your goals?
Have you participated in any other programs focused on recovery or sober living? Yes ☐ No ☐
- If yes, can you share your experience? (What program, how long, why you left)
What main challenges have you faced in maintaining your sobriety or in achieving your goals?
What strengths do you have that could help possibly benefit you and your success in this program?
(We believe in you & know you have strengths, even if it’s hard to see them sometimes)
LEISURE ACTIVITIES + SPECIAL INTEREST
List your favorite hobbies or forms of recreation:
How do you like to spend your free time?
GENERAL SOCIAL DATA
List any family deaths that affected you?
Were you a victim of sexual abuse? (Please share basic background per your comfortable level)
Please list any other life, crisis or major losses, (witnessed violence/tragedy, death of a pet, etc.)
Did you get help, use chemicals, or just survive these crises/hardships?
ALICE’S
HOUSE
Women's Recovery Program
YOUR COMMITMENT
Are you committed to working and or volunteering while at Alice's House? Yes ☐ No ☐ - If no, please explain. (Working or volunteering is mandatory for all residents to contribute to the community and support your recovery)
Are you able to pay weekly rent during your stay? (Rent is mandatory to help us maintain the program and services, and we will discuss what works for you) Yes ☐ No ☐ - If no, please explain any barriers to paying rent:
Are you committed to attending daily AA or NA meetings? Yes ☐ No ☐ - If no, what concerns do you have?
Are you prepared to engage with the program seriously and fully commit to your recovery journey at Alice’s House? Yes ☐ No ☐- If no, please share any concerns or barriers you have:
ANYTHING ELSE YOU WOULD LIKE TO INCLUDE?
Please share any other information you find valuable for us to know at this point in time
AGREEMENT
By submitting this form, you’re sharing your story with us, and we deeply appreciate your trust. Please know that the information you’ve provided is kept private and will only be used to help us understand how we can best support you. This is a serious and compassionate program because addiction and recovery are serious matters. We encourage you to be as open and honest as possible so that we can help you succeed on your journey.
Applicant Signature: Date:
ALICE’S
HOUSE
Women's Recovery Program
ALICE’S
Serious Rules
Serious Care
OFFENSES RESULTING IN AUTOMATIC TERMINATION
- Unauthorized Overnight: Residents are not allowed to stay out overnight without proper authorization from the house director.
- Fighting: Any fighting of a physical nature is prohibited.
- Weapons: Knives and any other weapons of a threatening nature are prohibited.
- Theft: Any theft of Alice's property or another resident's property.
- Gambling: Gambling on Alice's property is prohibited.
- Falsification: Falsification of any Alice's document or verbal statement to Alice's staff/officers. Any resident caught signing the log for another resident will result in the termination of both residents.
- Smoking: All residents are to observe the state fire marshals regulation of not smoking in bed, smoking in any undesignated area, or smoking in any bathroom.
- Warrants/Arrest or Incarceration: Failure to provide at intake knowledge of any outstanding warrants, or arrest for any reason and any amount of time while a resident.
- Drinking/Drugging: The use or possession of alcohol or any mind or mood altering substance at any time is prohibited.
- Urine Samples: Failure to provide a urinalysis sample and/or breathalyzer test upon request by staff members.
- Results of Urinalysis: Positive results from any urinalysis and or breath testing by a staff member.
- Rent: Unwillingness to assume financial responsibility for rent and/or fees.
- Probation: Failure to provide staff with information and conditions of probation during intake or if placed on it while a resident at Alice’s.
Automatic Termination Offenses are IMMEDIATE
What to know BEFORE applying to Alice‘s House
Failure to keep your appointment will result in the loss of your fee. You will be removed from the waiting list and will not be eligible to re-apply for thirty (30) days. This fee is non-refundable and non-transferable, regardless of the screening determination.
RENT: minimum $120/week, Due SATURDAYS by 10am NOTE: 2 weeks rent due at Intake
Alice’s is more than a group home or shelter, its a post-treatment/recovery program dedicated to helping you regain an independent, substance-free lifestyle. During your 180 to 2-year program, you will be required to become as self-sufficient as possible and to actively cooperate with all aspects of programming, including the provided list here.
- You will be required to review & accept the rules, policies, and regulations of the house.
- You will not use substances. Substance abuse of any kind will not be tolerated as a resident.
- You must sign legal consent to the release of your information for Alice’s to collaborate with the agencies, doctors, and therapists, with which you are involved.
- Your personal living area will be subject to inspection and searched per support staff discretion.
- You will be subject to random drug screenings at support staff's discretion.
- You will stay on your prescribed medication(s).
- You will deal responsibly with your legal, financial, family, and mental & physical health needs.
- You will be expected to find a job, hold a job, or if legally disabled, volunteer your time meaningfully.
- You will be expected to be employed or have a volunteer position within 30 days of your intake.
- You will be required to show proof of insurance & registration with a valid driver's license for any vehicle you use while a resident. All documents must be in your name.
- You will attend mandatory AA and or NA meetings & recovery groups.
- You will be referred to a therapist, depending on your needs.
- You will share household chores, including some meal preparation.
- Your progress toward your program goals will be evaluated weekly by the house support.
- We operate on a demerit system. If rules are not followed, termination of residency can result.
- You are welcome to attend religious services of your choice, Alice's is not religiously affiliated.
- You are required to complete assignment tasks & homework given to you on time.
- You are required to be ready and on time to engage in all scheduled groups.
NOTE: Future employment & income can signal recovery in progress, not recovery achieved. Alice’s support system can help you manage growth to prevent relapse.
At Alice’s, we prioritize your recovery & well-being, understanding it will impact all areas of your life. We expect you to approach your recovery with the same dedication and seriousness, aware your efforts will determine your recovery journey and success.