My Sistah's House Survey
RequiredRequired Question(s)
These rules are designed to keep us all safe at home.
 
Required 1.

Check each box below and initial at the end to acknowledge that you have read and understood the following rules: 

The safe house must remain clean and organized in all areas of the house. Make sure the safe house is clean and properly locked and secured at all times.
No overnight visitors. No exceptions.
Residents are not permitted to use or possess alcohol or illegal drugs on or off the property for the length of their stay. Anyone under the influence of alcohol or drugs will not be admitted in.
The safe house is not responsible for any personal items left during the day.
Personal belongings will be disposed of 48 hours after a resident leaves the safe house.
Residents must enter using the designated door only. They may never open the door for anyone, including other residents of the safe house without the approval of the safe house Rseident Advisor. No exceptions.
Residents can go through the intake process for the safe house M-F, 24 hours a day depending on staff/volunteer availibility. Saturday and Sunday hours vary.
  • Comment:

  • 500 characters left.
Required 2.
There is a 10pm curfew in effect each day. Missing curfew is a rule violation. Two missed curfews will place the resident on probation of the remainder of their initial offer of temporary 30-day housing. Any rule violation thereafter will result in voluntary termination of housing, effective 72 hours after notice of termination. This 72 hour period is contingent on which rule or rules have been violated and the attitude of the resident after notice of termination. The Housing Ambassador will exhaust all resources to assist with relocating. Resident will be eligible for rehousing at MSH 30 days after leaving. Exceptions must be approved 24 hours in advance by Kayla Gore and/or safe house Ambassador. If you agree to the curfew rules check yes and initial below:
Yes
No
  • Comment:

  • 500 characters left.
Required 3.

Check each box below and initial at the end to acknowledge you have read and understood the following rules: 

No weapns of any kind are permitted in the safe house.
No fighting, foul, or abusive language (arguing or petty bickering) is allowed. Respect each other.
This is a tobacco-free facility, No smoking in the front. Smoking is permitted on the premises only in designated areas.
Residents are not permitted to operate laundry room equipment without permission.
No loitering around the building before or after hours.
The safe house is for short term stays only.
Residents are expected to be involved in any activity requested by My Sistah's House Staff during their stay at the safe house.
Residents cannot miss any appointments set by My Sistah's House. No exceptions.
Due to sensitive documents in the office upstairs and for privacy of the Resident Assistant/Housing Ambassador NO ONE is allowed upstairs unless given explicit permission from Exectutive Director.
Violation of any rule may result in diciplinary action up to and including termination of your stay at the safe house. Residents who are dismissed for violation of any rule may not be able to return to the safe house for a minimum of 30 days.
Rules and regulations may be changed at the discretion of the Housing Ambassador/Resident Assistant in order to promote a safer environment for everyone at the safe house.
  • Comment:

  • 500 characters left.
Required 4.
The safe house has very strict rules about confidentiality. The safe house Ambassadors will not tell anyone who calls or comes here that you are here for your own safety, nor will we disclose any resident's reasons for being here in the safe house. If you talk to the safe house Ambassador about personal things they will not tell other residents. We will, however, share some information by having you sign a Consent for Release Form. Please check yes if you have understood our Confidentiality Agreement and initial below:
Yes
No
  • Comment:

  • 500 characters left.
Required 5.
Please electronically sign this document below

First Name:
Middle Name:
Last Name: