Residence Application

Personal Information

Name:

Preferred Pronouns:

Date of Birth (Year-Month-Day)

Phone

Ethnicity:

If no phone, indicate another way we can reach you:

Current Address:

City

State

Zip Code

Date requested to move in:

Emergency / Medical Contacts

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Do you have a Mental Health Therapist?

Yes

Name

Phone Number

Do you have a Primary Care Physician?

Yes

Name

Phone Number

Do you take prescription medications?

Yes

If yes, list your current medications and what they are prescribed for.

List any other medical or mental health issues we should be aware of.

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General Information

Are you legally eligible for employment in the United States?

Yes

Are you 18 or older?

Yes

Do you have a valid driver's license?

Yes

Criminal History

Have you been convicted of a misdemeanor or felony in the last 5 years?

Yes

If yes, describe convictions with dates.

Will you be on probation/parole while residing in home?

Yes

If Yes, Probation / Parole Officer's Name

Phone Number

Ingestion / Addiction History

Are you an alcoholic?

Yes

Date of last drink?

Are you a drug addict?

Yes

Date of last use?

List drugs of choice.

Do you have other addictions?

Yes

If so, list other addictions.

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Recovery Program

Do you attend a recovery program (AA, NA, RD, etc)?

Yes

How many meetings do you attend per week?

Do you have a sponsor/mentor?

Yes

When was the last time you met?

Sponsor/mentor's name:

Phone Number:

Are you currently in a treatment program or participating in drug court?

Yes

Name or contact:

Phone Number:

Describe your personal recovery plan to maintain abstinence:

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Current Employer or Volunteer Position:

Position

Phone Number

Employer Address:

Salary or Wage:

Date Hired:

Supervisor Name:

Supervisor Phone Number:

References

Provide three references who are not related to you and who have knowledge of your commitment to recovery.

Reference One Name:

Reference Phone Number

Reference One Address:

Reference Two Name:

Reference Phone Number

Reference Two Address:

Reference Three Name:

Reference Phone Number

Reference Three Address:

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I certify the facts contained in this application (and accompanying documents, if any) are true and complete. I understand any false statement, omission, or misrepresentation on this application or accompanying documents is sufficient cause for refusal for residence or for eviction, regardless of when discovered by STEP, Inc.

I authorize STEP, Inc. to obtain additional information about all statements contained in my application and/or accompanying documents, and I authorize any person, educational or other institution, or organization, unless otherwise noted, to disclose in good faith any information they may have regarding my fitness for residence. In addition, I release STEP, Inc. and any other persons giving reference on my behalf from any liability from the exchange of information and any other reasonable and necessary information incidental to the process.

BY SIGNING THIS APPLICATION, I CERTIFY THIS APPLICATION WAS COMPLETED BY ME, AND ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Applicant's Name:

Date

Select date.

Submit

Thank you!

We will contact you soon.

Application for Renewal Recovery Residence

Personal Information

Emergency / Medical Contacts

General Information

Criminal History

Ingestion / Addiction History

Recovery Program

Employment / Volunteer Information

Current Employer or Volunteer Position:

References

Thank you!

Main Office

11 N 26th St

Billings, MT 59101

406.248.2055

800.820.4180