Kiosk Beyond Brink Consent

Housing Application Questions

Please enter NA for any items that are required if this field does not apply to you.

Social Security Number*

Date of Last Use*

Alcohol and/or Drug(s) of Choice*

Date you are looking to enter sober living:*

Desired House:*

Chestnut House
Women's House
Creative House: LGBT+
Walnut House
Hickory House
Owatonna Men’s Housing Program

Chestnut House is a co-ed based residential living environment for those waiting to get into a treatment facility (pre-treatment) and for those who have already completed a resident treatment program (post-treatment).
Men’s recovery houses are all-male based residential living environments.
Women’s recovery house is an all-women based residential living environment.
Creative House is a residential living environment for LGBTQ+ persons and allies, which does not base living assignments on gender.

Mailing Address (if different than above):

Street Address Address Line 2 City State ZIP Code

Are you currently homeless?*

Yes
No

If so, in which county?*

Do you have any children?*

Yes
No

If yes, do you currently have physical or legal custody?*

Yes
No
Not Applicable

Are you currently going through charges or a chips case in court?*

Yes
No

If yes to charges/chips, please explain:*

What is your current form of transportation?*

Has a reliable car
Relies on others
Uses public transportation

What is the status of your driver's license?*

Valid
Suspended
Revoked
Never Issued

Emergency Contact Name

First Last

Emergency Contact Phone Number*

Emergency Contact Relationship to Participant*

Emergency Contact Relationship if Other*

Are you currently in inpatient treatment, jail work release, halfway house or any other structured facility other than the community or home , OR are you engaged in an outpatient program?*

Yes
No

(Please note: If you are in an OUT-Patient facility PLEASE use this section to fill in IOP information and note this is an out patient facility at this time.)

If YES, please provide the following information:

Facility Name:*

Enter NA if not applicable.

Counselor's Name:*

Enter NA NA if not applicable or unsure.

First Last

Facility Address*

Enter NA If not applicable.

Street Address Address Line 2 City State ZIP Code

Facility Phone*

Enter 000-000-0000 if unknown or not applicable.

Facility Email*

Enter no@email.com if unknown or not applicable.

Anticipated Discharge Date*

If NO, have you had any treatment services in the last 90 days?*

Yes
No

Do you have any mental or physical disabilities that would interfere with your participation in our program?*

Yes
No

If yes to any physical or mental disabilities, please explain:*

Enter NA if not applicable.

Do you have a Mental Health Diagnosis?*

Yes
No

If yes, please list diagnosis below. If no, enter NA.*

Medications you are currently prescribed:*

Enter NA if none.

Physical Limitations:*

Enter NA if none.

Have you been arrested in the last 30 days?*

Yes
No

Are you now on Probation?*

Yes
No

Are you now on Parole?*

Yes
No

Probation/Parole Office Name & Number/Email, Address and County where they are located:*

Enter NA if not applicable.

List felony convictions, if any:*

Enter NA if none.

List misdemeanor convictions, if any:*

Enter NA if none.

If you have a Case Manager, please list Name & Number/Email, Address and County where they are located:*

Enter NA if not applicable.

Do you have any specific legal restrictions?*

Yes
No

If yes to specific legal restrictions, please describe:*

Enter NA if none.

Have you ever been charged with any violent crimes?*

Yes
No

If yes, please describe IN DETAIL the events of all violent crimes. Use a separate page if necessary. (We consider Violent Offenders on a case-by-case basis.)*

Enter NA if not applicable.

Were you under the influence of drugs/alcohol when you committed the crime?*

Yes
No
Not Applicable

Do you currently have a sponsor, mentor, counselor, pastor, or Peer Recovery Specialist you are working with?*

NOTE: Beyond Brink Recovery Housing requires you to obtain within 2 weeks of entering the program.

Yes
No

Are you currently attending support meetings of any kind?*

NOTE: Beyond Brink Recovery Housing requires attendance to 3 support meetings per week once in the program.

Yes
No

What things do you do currently to maintain your recovery? What do you need to do?*

Please share what you would like to do if accepted into the Beyond Brink Recovery Housing. What type of job will you be looking for? School? What are your plans to start to rebuild yourself in this community? How long do you see yourself staying with us? What does recovery mean to you?*

Is there anything else you would like to share?*

By signing below, I understand and agree to meet the following expectations, if accepted for residency into Beyond Brink.

I agree to remain abstinent while living in Beyond Brink housing program.
I agree to pay my portion (if any) of the resident fee as agreed.
I agree to always keep Beyond Brink free from alcohol, illegal drugs, & mind-altering substances.
I agree to enter into a resident agreement (following all resident rules and expectations for structure and accountability) and abide by the terms.

Please enter your initials to acknowledge agreement with the above terms.*

Consent*

I certify that ALL information I have provided to Beyond Brink is true and correct. I have read all material on this application form including the limitations above. I have answered each question honestly and want to achieve long-term sobriety from alcoholism and/or addiction. When I am accepted and take residency, I agree to hold harmless Beyond Brink, the property owners, and all service providers, and agree to sign the Resident Release and Hold Harmless form, the Resident Agreement, the medication watch agreement, any releases requested by Beyond Brink, and the House Rules and Expectation Agreement.

Step 1 of 14

Face Sheet

Demographic Information

Insurance and Medical Information

Additional Forms:

Housing Application Questions

Informed Consent

Notice of Privacy Practices, Page 1

Notice of Privacy Practices, Page 2

Bill of Rights

Grievance Procedure

Acknowledgement of Important Documents

Authorization for Release of Information

Resident Agreement

Resident Agreement Consent

Release and Hold Harmless

Medication "Watch" Program Authorization Form

Housing Support/GRH Acknowledgement Form

Authorization to Release Personal Property

Agency/Person	Phone