Residence Application – STEP: Support and Techniques for Empowering People

Personal Information

What date would you want to move in?

Name:

Preferred Pronouns:

Date of Birth

Ethnicity:

Current Address:

City

State

Zip Code

Phone

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

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 concerns we should be aware of.

Have you experienced domestic violence?

Yes

Please write out your preferred plan, should you resume use. This plan should include what we should do, whom we should contact, and where we should take you (if we are able), should you experience a relapse.

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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

If no drivers license, give the reason.

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

Substance Use History

Date of last use?

List substances of concern.

Other behaviors of concern?

Yes

If so, please list.

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Recovery Program

Do you attend a recovery program (AA, NA, RR, PAR, GA, SA, etc)?

Yes

If so, how many meetings do you generally 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:

Job Description:

Date Hired:

Supervisor Name:

Salary or Wage:

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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Admittance into STEP's Renewal Recovery Residence requires that the applicant be age 18 years or older, not require additional supports for a severe mental health diagnosis, not be required to register as a sex offender, identify as having a drug or alcohol addiction, and are committed to recovery. Based on the application and results of an interview and additional steps of the process, management makes the determination regarding admitting the applicant. The applicant is notified promptly of the admittance decision.

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

Substance Use History

Recovery Program

Employment / Volunteer Information

Current Employer or Volunteer Position:

References

Thank you!

If you prefer, you can download, print, fill out, and mail the form to:

STEP
11 N 26th St
Billings, MT 59101

Main Office

Application for Renewal Recovery Residence

Personal Information

Emergency / Medical Contacts

General Information

Criminal History

Substance Use History

Recovery Program

Employment / Volunteer Information

Current Employer or Volunteer Position:

References

Thank you!

If you prefer, you can download, print, fill out, and mail the form to:

STEP 11 N 26th St Billings, MT 59101

Main Office

STEP
11 N 26th St
Billings, MT 59101