Wilson Housing Alliance Recovery Housing Application

Welcome to Wilson Housing Alliance

We are honored to walk alongside you on your journey of recovery. Wilson Housing Alliance was founded by individuals who have personally experienced the challenges of addiction and the transformative power of recovery. Our mission is to provide stable, supportive housing to individuals in recovery while empowering each resident to pursue lasting change with dignity, accountability, and hope.

This application packet outlines everything you need to know about becoming part of our recovery home. Please read it carefully and honestly. Our program is designed to support you but success depends on your willingness to engage, grow, and commit.

We offer structure, support, and a clean and sober living environment rooted in compassion, community, and personal responsibility. Our staff and volunteers are here to help, but your journey is your own.

I have read and understood the "Welcome" section.

Program Structure Overview

Wilson Housing Alliance operates in two structured phases:

Phase 1: Initial Residency

The Initial Residency phase is a 3-month introductory period. During this time, new residents are welcomed into a safe and structured recovery environment where they can stabilize, gain momentum in their sobriety, assess their readiness for longer-term commitment and complete outpatient treatment. This phase includes close support, clear expectations, and opportunities for connection and reflection. Residents are expected to participate fully in recovery-based activities, maintain sobriety, follow house rules, and demonstrate a commitment to living in community with others in recovery.

One-time Intake Fee: $300
Monthly Contribution: $700
Increased accountability and staff engagement

Phase 2: Full Residency

After completing the Initial Residency period, residents who wish to continue will meet with staff for a re-interview. This conversation will focus on progress made, current needs, and long-term recovery and life goals. Upon mutual agreement, residents will transition to Full Residency status. Full Residents are given more responsibility and trust within the household and are encouraged to pursue life goals such as employment, education, and family restoration. Residents at this stage serve as role models for others.

Monthly Contribution: $800
Increased autonomy and individualized program support
Ongoing goal setting and mentorship
Visitors are approved on a case-by-case basis to support family restoration.

I have read and understood the "Program Structure Overview".

Program Policies & Guidelines

LANDLORD TENANT RULES DO NOT APPLY TO TEMPORARY HOUSING

Please read the following policies carefully by expanding each section. You will be asked to acknowledge them at the end.

Living in a Wilson Housing Alliance Home

Wilson Housing Alliance is a recovery-based supportive living program. All residents are expected to uphold our core values: dignity, accountability, mutual respect, and a commitment to personal growth. To create an environment that fosters long-term sobriety and stability, the following guidelines must be followed. These rules ensure safety, structure, and consistency for everyone in the house.

All Phase 1 residents are required to successfully complete their outpatient treatment program, as well as any court-mandated or referring agency program requirements. All Phase 2 residents are required to be Employed and or Enrolled in an accredited Education program/ school within 30 days of their transition to full residency.

Productive Engagement Requirement

Residents are required to be actively engaged in employment, volunteer service, or an approved educational or training program within 30 days of entering phase 2 of the program. We believe idle time undermines the recovery process. Our staff will support you in finding appropriate opportunities if you need help meeting this requirement.

Recovery Meeting Attendance

Residents are required to attend a minimum of one (1) recovery meeting per week, such as AA, NA, Celebrate Recovery, or another program approved by staff. If you are in formal outpatient treatment, that may count toward this requirement. Attendance verification (e.g., a signed meeting slip) may be requested.

Attendance and Absence Policy

No-call / no-show absences exceeding 48 hours are grounds for dismissal. You must notify house staff if you plan to be away for more than 24 hours and receive approval prior to leaving. If you are involved with the Department of Corrections (DOC), only your Community Corrections Officer (CCO) can approve overnight absences. If you are unaccounted for during curfew hours, your CCO will be contacted.

Cleanliness and Shared Responsibility

Rooms: Beds must be made daily (when not occupied). No food is allowed in bedrooms. Shared rooms must be kept tidy. If a bed in your room is unoccupied, you may not place items on or under it.
Chores: Each resident will be assigned rotating weekly or monthly chores, including deep cleaning of kitchens, bathrooms, and common areas. If you are unable to complete a chore, it is your responsibility to find a replacement.
Inspections: Weekly house inspections will occur, with report cards issued. The house must maintain a minimum passing grade of B-.

Privacy, Conduct & Substance Use

Privacy and Accountability

Search Policy: Rooms and belongings may be searched at any time for drugs, alcohol, weapons, or other contraband. There is no expectation of privacy in shared living environments.
Law Enforcement Access: Staff and DOC personnel may enter the property at any time. All residents are expected to cooperate with inquiries from DOC, even if they are not currently under supervision.

Conduct and House Culture

Respect personal space. No sexual or romantic relationships between residents.
No pets or animals are permitted, including service or emotional support animals, due to the communal living environment.
No guests are allowed at any time. Overnight visitors, including family, are strictly prohibited.
No persons under age 18 are allowed on the property unless pre-approved in writing by staff and child welfare agencies (e.g., CPS).
No external romantic partners are allowed on-site for any reason.

Substance Use Policy

This is a zero-tolerance clean and sober environment. The use of alcohol, drugs, or marijuana (even if prescribed or legal recreationally) is not permitted. Baseline and random drug/alcohol screenings will be conducted. Refusing a UA, failing a UA, or tampering with samples may result in immediate discharge. Providing drugs, alcohol, or paraphernalia to another resident will result in immediate expulsion. All prescription medications must be approved, stored securely, and disclosed to staff. Narcotics and controlled substances are subject to review.

Property, Safety & Community

Personal Property and Finances

We strongly discourage lending or borrowing money between residents. Do not bring valuables exceeding $50 in value, aside from your cell phone. Shared spaces are not secure storage areas. Any items left behind for more than 10 days after departure will be considered abandoned and may be donated or discarded. If you own a car, it must be legal, insured, and operable. We are not responsible for theft or damage. Parking is first come, first served.

Safety and Behavior

Smoking, vaping, or chewing tobacco is allowed only in designated outdoor areas. Not on the front porch or inside any part of the structure. Stealing, including taking food, medication, or other residents' property, will result in immediate termination. No open flames. Candles, incense, and use of fireplaces/wood stoves are not permitted. Deliberate property damage will result in financial liability. If no individual claims responsibility, the cost may be shared among all residents. Sharing door codes is prohibited. If you allow unauthorized access, you may be exited immediately.

Curfew: Sunday through Thursday: 10:00 PM. Friday and Saturday: 12:00 AM. Exceptions must be approved in advance by staff. If under DOC supervision, curfew will also be monitored by your CCO. You may be required to submit a copy of your work schedule.

Technology and Communication

Computers and printers (if provided) must remain in the designated common areas. Use of personal devices must not interfere with others' recovery or the peace of the house.

Community Conduct

We ask that all residents behave in a friendly and respectful manner toward neighbors. You are a representative of Wilson Housing Alliance while residing in the home. Please be courteous and avoid behavior that may generate complaints or conflict with the surrounding community.

Legal-Involvement Policy

If you entered the Wilson Housing Alliance program as part of a legal, diversion, or court-related arrangement and you violate the terms of your stay-such as by being incarcerated-we may or may not be able to hold your room. A case-by-case determination will be made in consultation with your community corrections officer (CCO), treatment providers, or legal representatives to evaluate the best course of action. While we will take professional input into account, the final decision regarding your continued placement or reentry will be made solely by Wilson Housing Alliance. This program operates under the provisions of RCW 59.18.550 as a drug- and alcohol-free housing initiative committed to supporting recovery through accountability.

I acknowledge that I have read and understood all policies listed above.

Client Intake Information

Name *

Date *

Birth Date *

Age

Phone *

Email *

Agency Affiliation (if any)

Veteran *

Yes

No

ID Card? *

Yes

No

SSN Card? *

Yes

No

Financial, Health & Legal History

Income (Check all that apply) *

Working

DOC Housing Voucher

SSI

SSDI

Other

Healthcare (Check all that apply)

Medicaid

Medicare

Both

Other

Barriers to Housing (Check all that apply)

Eviction

Debt

Other

Please describe any past or present mental health history. * Please list the mental health services you currently receive. *

Please describe your history of substance use or addiction. * Please list the substance use services you currently receive. *

Incarceration or Arrest History (Any pending charges?)

Work History & Plans

Are you currently working or actively looking for work? *

Yes

No

Type of work (or desired field)

Work History (Briefly describe your past 2-3 jobs)

Highest Education Level

Do you plan to enroll in school or job training? *

Yes

No

Type of training or program

What should we know about you to assist you? Please feel free to write below.

Emergency Contacts / Family or Friends

Resident Signature

By signing below, I affirm that all information provided in this application is true and accurate to the best of my knowledge.

Signature *

Printed Name *

Date *

Terms & Agreements

Involuntary Termination of Residency

Please initial next to each item to acknowledge you understand these are grounds for immediate termination.

Client Terms and Conditions

Please initial next to each item to acknowledge your agreement.

Agreement Signature

Signature *

Print Name *

Date *

Authorization for Release of Information

Click to Read Full ROI Instructions

ROI's must be completed in blue or black pen to be processed. All writing must be legible for records to be released. The ROI form allows Wilson Housing Alliance to communicate with providers or parties involved in your treatment, legal case, or recovery plan. This information may be necessary to confirm eligibility, monitor progress, or coordinate services. You have the right to limit what information is released and to whom. Signing the ROI is voluntary but may impact our ability to assist you if not completed.

Applicant's Information: On the top of the ROI, it will ask for applicant's name and Date of Birth (DOB). Applicants name must include both first and last name for the request to be fulfilled. If the applicant has a previous last name, you will need to complete a separate, independent ROI form to request the records for each name.

Person/Agency Receiving Information: This section must include the complete name of the person we will be releasing records to. If the person requesting the records is the same person we will be releasing to, we will still need the complete name. All ROI's must include the complete mailing address in this section for release. We use this for verification and an alternative method of release in case we are unable to fax or email. If you would like records emailed or faxed, the email address will need to be provided in this section. Please make sure that they are clear and legible. If there is a preferred method you would like the records to be released, please circle the preferred method of release in this section. We will attempt to accommodate all requests; however, may be denied due to fax and email limitations. If we are unable to release by fax/email, we would then mail the records out or prepare for pick-up if the option is checked off on the ROI form.

Information to be disclosed: This section indicates which specific records you are authorizing for release. If you are still unsure which one to check off, please feel free to use the "Other" option and write which records you are authorizing for release.

Dates of Records: ROI's can be used for extended release for up to a year, if there are no changes. If you would like to use this option, you will need to complete the section that states, "I revoke this authorization" and either use the date that is 1 year from the date you are signing the ROI form or you may check off one of the other options listed in this section.

Name

Date

Person/Agency authorized to make the disclosure:

Wilson Housing Alliance
4920 Evergreen Way South #1106
Everett WA 98203

Person/Agency Receiving the Information:

Name

Phone #

Address

E-mail

Pick Up

Fax #

Dates of Records:

From:

to:

OR if no dates,

years will be released.

Check here if each of the above parties may disclose your information with the other party. The above information may include records of drug abuse, alcoholism, medical history, criminal history, residency history.

Purpose for Disclosure:

I understand I may revoke this authorization at any time by writing to Wilson Housing Alliance. The revocation will be effective except to the extent that action based on this authorization has already been taken. Wilson Housing Alliance may not condition eligibility for housing on whether the consumer signs the authorization. The information used or disclosed by this authorization may be at risk for re-disclosure by the recipient and no longer protected by federal privacy laws.

This consent will expire (Check all that apply):

Upon denial of application for residency

Upon termination of residency

Signature of Applicant

Date of Signature

Notice: Alcohol and drug abuse patient records are protected by Federal confidentiality regulations (42 CFR part 2). The Federal regulations prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release medical or other information is NOT sufficient for this purpose. The Federal regulations restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Communicable disease related information, pursuant to this release, cannot be re-disclosed without specific authorization. (A.R.S. 36-664.H)

HIPAA & Final Agreement

Authority for Release of PHI Under HIPAA

This section shall be interpreted to specifically allow for the release to Wilson Housing Alliance (WHA) of any information subject to the provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). 42 U.S.C. 1320d and CFR 160-164.

The Principal authorizes any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider, any insurance company and the Medical Information Bureau Inc. or other health care clearinghouse that has Principal for such services, to give, disclose, and release to the WHA, without restriction, all of Principal's individually identifiable health information (as defined in HIPAA), financial and billing records, and medical records regarding any past, present or future treatment of HIV/AIDSs, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The Principal understands that once the foregoing information is disclosed, it may be redisclosed by the WHA and the information may not be protected by federal or state privacy laws or regulations. This authority given to the WHA shall supersede any prior agreement that the Principal may have made with Principal's health care providers to restrict access to or disclose of Principal's individually identifiable health information. This authority given to the WHA has no expiration date and shall terminate only in the event that the Principal revokes this authority in writing and delivers it to Principal's health care provider. The Principal hereby waives the physician-patient privilege as to all communications between any physician (or other health care provider) and the Principal and Principal to the extent necessary to permit any such physician (or other health care provider) to disclose to the WHA all such individually identifiable health information.

Principal Signature *

Principal Print Name *

Date *

Final Agreement

By signing below, I acknowledge that I have read, understood, and agree to follow all rules, policies, and procedures outlined in the Wilson Housing Alliance Resident Application Packet. I understand that failure to comply may result in disciplinary action, including possible termination of residency.

Resident Signature *

Resident Name (Printed) *

Date *

Review & Submit Your Application

You're almost done! Please click the "Preview PDF" button to review your completed application. Ensure all information is correct before submitting.

Resident Intake Form

Welcome to Wilson Housing Alliance

Option 1: Complete Online (Recommended)

Option 2: Download Blank Form

Download Started

Recovery Housing Application

Welcome to Wilson Housing Alliance

Program Structure Overview

Phase 1: Initial Residency

Phase 2: Full Residency

Program Policies & Guidelines

Productive Engagement Requirement

Recovery Meeting Attendance

Attendance and Absence Policy

Cleanliness and Shared Responsibility

Privacy and Accountability

Conduct and House Culture

Substance Use Policy

Personal Property and Finances

Safety and Behavior

Technology and Communication

Community Conduct

Legal-Involvement Policy

Client Intake Information

Financial, Health & Legal History

Work History & Plans

Emergency Contacts / Family or Friends

Resident Signature

Terms & Agreements

Involuntary Termination of Residency

Client Terms and Conditions

Agreement Signature

Authorization for Release of Information

HIPAA & Final Agreement

Authority for Release of PHI Under HIPAA

Final Agreement

Review & Submit Your Application

Thank You for Your Submission!