SteadyStep Membership Assessment
Please complete the application form . Incomplete Applications will not be considered for program membership.
Date
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Month
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Day
Year
Date
Full Name
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First Name
Last Name
Email Address
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Phone Number
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Date of Birth
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Month
-
Day
Year
Date
Gender
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Female
Male
Marital Status
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Single
Separated
Married
Divorced
Current Address
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What is your current housing situation ? How long have you been there ?
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Do you currently have a case manager, social worker, or program contact?
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Yes
No
If 'Yes", please provide their name and contact info.
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If you are in transition, please let us know which of the following best reflects your situation.
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Rehabilitation
Homelessness
Substance Abuse Recovery House
Domestic Violence Shelter
Mental Health Facility
Recently Incarcerated
Senior Living Facility
Eviction
Other
Are You Currently Employed
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Yes
No, but I'm seeking employment.
No, but I have a source of income.
Income Source (must be verifiable)
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SSI/SSDI
VA Disability
3rd Party Organization Payments
Job/ Paycheck
Other
Monthly Income Amount (must be verifiable)
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PAYEE NAME (IF APPLICABLE)
First Name
Last Name
Are You a Veteran
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Yes
No
Do you have a reliable source of income to pay the one time $300 community fee at move in and the $750 monthly room program fee ? (Please note that this all-inclusive rate is per individual)
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No,
Yes
When are you planning to move in ?
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Immediately
Within 1-2 weeks
Within 2-4 weeks
Will you be the only person moving in or are you planning to have someone else move in with you ? (separate application and approval required for each adult )
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Yes, I will be the only person.
No, someone will move in with me.
We offer Co-Ed (Men & Women), Women-Only, and Men-Only residences. Please select the option you feel most comfortable with.
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Women Only
Men Only
Co-Ed or Whichever is available for immediate move in
Do you have any pets that you plan to bring with you ?
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Yes
No
Do you require any daily assistance with personal care (such as bathing, dressing, medication management or mobility ) ?
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No I don't.
Yes, I require minimal assistance.
Yes, I require complete daily assistance.
Do you understand this program is for independent adults (not assisted living, group home, or medical housing ) ?
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I understand.
I do not understand.
If you are prescribed medications, do you take them independently? * Please note: Steadystep is not a medical facility and cannot administer medication.
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Yes, I take my medications independently.
No, I require assistance.
I do not take any medications.
Can you manage your own meals, laundry and cleaning of your living space without onsite staff support ?
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Yes
No, I require assistance.
Are you comfortable living in a shared home where common areas such as kitchen, bathrooms, living room, and laundry rooms, are used by other members in the residence?
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Yes
No
Are you comfortable sharing a bedroom with at least 1 other member of the residence?
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Yes, I'm just looking for clean, safe and affordable housing at $25 a day ($750 a month) Including utilities & WiFi
No
Do you have a vehicle ?
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Yes
No
Have you ever lived in shared housing before ? If yes what was that experience like ?
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Have you ever been convicted of a violent crime or property damage? Please note, answering 'Yes' does not automatically disqualify you.*
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Yes
No
Have you ever been convicted of a sexual offense? Please note, answering 'Yes' does not automatically disqualify you.*
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Yes
No
Do you have any pending criminal or pending sexual convictions ? Please note, answering 'Yes' does not automatically disqualify you.*
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Yes
No
Are you currently on Probation ?
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Yes
No
If you are on probation , what are the conditions ?
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Have you ever been diagnosed with a mental health condition or received mental health treatment? (your response helps us understand any accommodations or resources you may need)
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Yes
No
Have you had frequent 911 calls related to personal mental health crises?*
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Yes
No
Do you require medical supervision or specialized support services to live safely day to day ?
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Yes
No
How many hospitalizations have you had in the past 3 months?*
Do you currently use any substances (Drugs Or Alcohol ) ? If yes, what is your substance of choice?*
Our residences are alcohol & drug free (including marijuana), are you able to comply with that requirement ?
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Yes
No
Can you agree to follow all program rules, including quiet hours, visitor policies and cleanliness standards?
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Yes
No
Have you ever been asked to leave a residence due to behavior , rule violations or disturbances ?
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Yes
No
How do you typically handle disagreements with roommates or neighbors?
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Do you have a reliable source of income to cover the preferred monthly room program fee and your personal expenses each month ?
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Yes
No
To ensure we place you in a unit that works best, can you comfortably use 15 stairs to access bedrooms on the 2nd floor ?
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Yes
No
Emergency Contact
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example@example.com
Are you currently receiving support from any community agencies? If yes please list all.
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Upload a copy of your proof of income : Acceptable proof includes paystubs , Social Security, pension, VA, unemployment, disability, or assistance award letters. You may also upload a recent bank statement showing benefit deposits or a 1099 form. Documents must show your name, benefit type, and monthly amount.
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Upload a copy of your ID
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What are three goals you would like to accomplish while in this program?*
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How did you find out about us ?
*
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