SteadyStep Housing Program Assessment
Please complete the application form . Incomplete Applications will not be considered for program (Program availability is subject to change. Submission of an application does not guarantee placement)
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
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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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Are you completing this form for someone else ? If so please state your relationship to the person
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Please let us know which of the following best reflects your housing situation.
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Rehabilitation
Homelessness
Substance Abuse Recovery House
Domestic Violence Shelter
Mental Health Facility
Recently Incarcerated
Senior Living Facility
Eviction
Other
How long have you been in your current housing situation ?
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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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Are You Currently Employed
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Yes
No, but I'm seeking employment.
No, but I have a source of income.
If Employed List your employer (put N/A) if not applicable
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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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If Employed what shift do you work (put N/A if this doesn’t apply )
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What is your Frequency of Income?
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Daily
Weekly
Bi-weekly
Monthly
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 monthly room program fee ? (Please note that this all-inclusive rate is per individual and per bed )
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No,
Yes
When are you planning to move in ?(please note program housing fee will be due prior to move in)
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Month
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Day
Year
Date
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
No
Do you have a vehicle ?
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Yes
No
Have you ever lived in shared housing before ?
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Yes
No
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
If you've been convicted of a Crime , please explain the charges and the most recent charge . Please note, answering 'Yes' does not automatically disqualify you but dishonesty will .*
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Have you ever been convicted of a sexual offense? Please note, answering 'Yes' does not automatically disqualify you.*
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Yes
No
If you've been convicted of a sexual offense , please explain the charge .
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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
If yes please provide details on the diagnosis ? (your response helps us understand any accommodations or resources you may need)
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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?*
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Do you currently use any substances (Drugs Or Alcohol ) ? If yes, what is your substance of choice?*
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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
For the safety and protection of all residents, please note that security cameras are installed in all shared common areas (such as hallways, kitchens, and living rooms) as well as at all exterior entrances and exits. There are no cameras inside bedrooms or bathrooms. Tampering, unplugging, or covering any camera is strictly prohibited and will result in immediate termination from the program and removal from the premises. Do you understand and agree to these conditions?
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Yes , I understand and agree
No , I don’t agree
Emergency Contact: (name , Phone number , email )
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Are you currently receiving support from any community agencies? If yes please list all.
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Upload a copy of your recent proof of income : Acceptable proof includes paystubs(within last 30 days) , 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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What type of support would you need from this program ?*
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How did you find out about us ?
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