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Home
Services & Programs
Services for Families & Children
Services for Adults
Renewal Recovery Residences
Our Leadership Team
Career Opportunities
About STEP
Community Resources
Contact
Donate Now
Application for Renewal Recovery Residence
Name:
Preferred Pronouns:
Date of Birth
Phone
Ethnicity:
If no phone, indicate another way we can reach you:
Current Address:
City
State
Zip Code
Email
Date requested to move in:
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Emergency / Medical Information
Emergency Contacts
Name
Relationship
Phone Number
Name
Relationship
Phone Number
Medical Information
Do you have a Primary Care Doctor?
Yes
No
Name
Phone Number
Do you take prescription medications?
Yes
No
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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Next
General Information
Are you legally eligible for employment in the United States?
Yes
No
Are you 18 or older?
Yes
No
Do you have a valid driver's license?
Yes
No
List any skills that you are interested in providing to trade for residence.
Criminal History
Have you been convicted of a misdemeanor or felony in the last 5 years?
Yes
No
If yes, describe convictions with dates.
Probation / Parole Officer's Name
Phone Number
Will you be on probation/parole while residing in home?
Yes
No
Addiction History
Are you an alcoholic?
Yes
No
Date of last drink?
Are you a drug addict?
Yes
No
Date of last use?
List drugs of choice.
Do you have other addictions?
Yes
No
If so, list other addictions.
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Recovery Program
Do you attend a recovery program?
Yes
No
How many meetings do you attend per week?
Do you have a sponsor/mentor?
Yes
No
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
No
Name or contact:
Phone Number:
Describe your personal recovery plan to maintain abstinence.
Write out a plan should you relapse, what we should do, who to call, where to take you.
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Thank you!
We will contact you soon.