STEP House Program: Welcome and Acknowledgement

STEP House Program: Welcome and Acknowledgement

Thank you for your interest in applying to the STEP house transitional living community. The STEP House program was created to support and assist women and their children as they transition from halfway houses, sober living programs or residential programs back into the community by providing affordable, stable and sober living communities.
Our approach is to meet the residents where they are and provide practical and holistic support that includes case management, financial education and personal and professional goals support. Housing units are filled based on availability and need. Individual leases will be obtained based on the individual’s needs, budget and financial abilities to pay. We are excited that you are interested in joining our program. To expedite the admissions process, please include the items listed below with your application packet.
Please note:

The STEP House program is unable to consider applicants who are registered on the sex offender registry or those with arson or violent assault charges.
Please include with your application (upload at end):

• Any letters of recommendation or referrals, especially from programs you have completed. • Any certificates of program completion (if applicable). • Court paperwork that includes your probation requirements. • Court paperwork that includes your visitation/custody rights.
Please check the boxes below to acknowledge you understand the following expectations and rules of the STEP house program.

I know that I am not permitted to work a third shift job.I will participate in ALL required STEP programming for the duration of my stay.STEP house staff reserve the right to ask me to leave the program/house immediately should it be discovered that I provided false or misleading information during the admissions process, as well as during my residency.The first 30 days of residency are conditional, and staff reserve the right to ask me to leave the program and house if it becomes apparent, I am not a “good fit” for the STEP program.I agree to abide by all policies, procedures, expectations, and standards of living set forth by the Step house program and understand that staff reserve the right to make changes to these during my residency.STEP house is a sober living environment, and I know that I may be discharged for using illegal substances and/or alcohol including anything that may cause a positive drug screen, legal or illegal (i.e. CBD, Kratom, etc.)STEP house reserves the right to discharge me should I fail to adhere to my transition/treatment plan, which includes bi-weekly individual meetings, financial advising and 12-step meetings and sponsorship.I agree to abide by all conditions of supervision set forth by any State or County Agency.I agree to diligently pursue a positive, self-sustainable lifestyle that includes, among other matters, legitimate income, independent living, and permanent housing.I agree to pay a $100 administrative fee upon arrival and begin paying housing fees in the amount of $200 per week beginning on the first day of residency.
Applicant's Signature

Powered by Jotform SignClear
Today's Date

MonthDayYear
Date
STEP Housing Program Application

Please note: This is an application and does not constitute acceptance into our STEP House program. If you are eligible, a follow-up interview or meeting will be scheduled, and additional information may be requested. Thank you!
Please provide all requested information and complete application fully – failure to do so will delay the admissions process or result in denial.
PERSONAL INFORMATION
Name

First NameLast Name
Alias
Date of Birth

MonthDayYear
Age
TDOC #
Mailing Address City State Zip
Phone Number
Please enter a valid phone number.
Current Living Situation

HomelessShelterResidential Treatment ProgramPublic HousingPrivate Housingwith Significant Otherwith Familywith Others
Have you ever lived or worked in Rutherford County, TN?

YesNo
If you answered 'YES' to the above question, when and for how long?
CURRENT STATUS
Re-Entry Counselor/Case Manager/ Parole officer Name:
Contact Email:
Direct Phone #:
List probation requirements:
Attach supporting documentation at end of application
PERSONAL SUPPORT
Closest Living Relative
Relationship
Closest Relative's Location
Is this person a positive influence in your life?

YesNo
Are you involved in any AA/NA/STEP work support group?

YesNo
If “yes”, name the group and location and date/time of the meetings you attend:
Do you have a sponsor?

YesNo
If “yes”, name the sponsor and indicate if you are currently working on the steps with them. (what step)
Marital Status

SingleEngagedMarriedSeparatedDivorcedNot Married, but in a relationship
If applicable, is your significant other a positive influence in your life?

YesNo
Do you have children

YesNo
If “Yes”, how many?
What are the demographics of your children?
Are you in regular contact with

Significant otherChildrenYour parentsOther familyOther significant people

Do you have any of the following rights with your children? (if yes, paperwork needs to be provided)

	YES	NO
Custody
Partial Custody
Visitation

If you answered “No”, do you want to work on getting visitation or custody of your children?

YesNo
**The STEP House Residency Program allows children 10 years of age or younger to spend the night in the houses. All other children are welcome to visit as long as proper documentation is given and visitation guidelines are followed.
ADDICTION & HEALTH HISTORY
Have you ever struggled with substance abuse/chemical dependency issues? (check all that apply)

YesNoCurrentPast
Clean Date:

MonthDayYear
If “Yes”, age of first use:
If “Yes,” check all that apply:

AlcoholMethamphetaminesAmphetaminesOpioids/HeroinCocaine/CrackMarijuanaOther (describe below)
If other, describe:
Have you ever participated in a substance abuse recovery, rehabilitation, treatment program or inpatient mental health treatment?

YesNo
If “Yes”, how many times?
Explain:
When/where was the most recent?
Please provide graduation certificates if applicable.
Have you ever struggled with any non-chemical, behavioral addiction? Examples may include gambling, food/overeating, sex, pornography, shopping/spending, etc.

YesNo
If “Yes”, describe your addiction(s):
Current or past:

CurrentPast
Have you ever been diagnosed with a psychological condition such as depression, anxiety, bipolar, schizophrenia, etc.?

YesNo
If yes, what is/was the diagnosis?
Are you receiving treatment or taking medication for the diagnosis?

YesNo
Please provide information regarding ALL legal prescription medications taken in the past three years:
EMPLOYMENT HISTORY
Are you currently employed?

YesNo
How long at your current job?
What is your position?
What is the longest time you've held the same job, and where?
If your answer was ‘No,’ what was the last job you held?
What are your future employment plans?
EDUCATION
Highest grade completed in school or GED/Hi-Set:
Year Completed
College/Post-Secondary Education (place and date)
Vocational/Trade School Certificates/Certifications
Do you want to further your education?

YesNo
Where do you want to be in 1 year?
Where do you want to be in 5 years?
VETERAN STATUS
Are you a veteran?

YesNo
If 'Yes', which branch?
Combat experience?

YesNo
Years of Service
Type of Discharge
RECORD OF CHARGES AND CONVICTIONS
** Please provide information pertaining to ALL charges and convictions regardless of location or outcome. ** (Use additional paper, if necessary). Writing “see attached” is not acceptable, this section must be filled out, or application may be denied for lack of completion.
Provide details of your most recent offense:
Why do you want to participate in our program?
Short-Term Goals (1st 90 days):
Long-Term Goals (6 months to 1 year):
CONSENT FOR RELEASE OF INFORMATION
I,(print name) ,do hereby grant, by signature, permission for representatives of the STEP House program to use my personal information and records as deemed necessary. I understand that I am granting permission for sharing personal information and records between the STEP House program representatives and with representatives of other entities, in particular representatives of the Tennessee Department of Correction or the Department of Mental Health and Substance Abuse Services. I further understand that the STEP House program staff members are bound, by law, to report knowledge of my intent to harm myself or others, or to report knowledge of children in danger of harm.
I understand that I am authorizing the release of any or all of the following (check all that apply):

Medical history, health status, diagnosis, examination, laboratory tests and treatment reports.Psychological evaluations and or psychiatric evaluation reports.Social history data (including family), education, and any other related material.Any information or documents held on-file by the STEP House program.
I understand that this information may be used for the following purposes:

● Reporting required by TDOC or grant funding reporting that may be acquired by the STEP House program. ● Coordination of medical, psychological, and social rehabilitation if deemed necessary. ● Development of a treatment and/or rehabilitation plan. ● Coordination of judicial issues. ● Internal digital confidential record-keeping.
Signature

Powered by Jotform SignClear
Print Applicant's First Name* Print Last Name* Today's Date
Upload supporting documentation below

Cancelof
Information obtained will remain confidential and only be shared in accordance with Federal Privacy Laws. Consent will remain effective for 90 days following completion of or termination from the Step Residence program.
Title VI Policy

It is the policy of the STEP House program to comply with Federal and State mandated Title VI legislation for the purpose of ensuring that its services do not discriminate against people because of their race, color, national origin or limited English proficiency. Should Title VI complaints arise, they will be addressed in a timely manner.
Should be Empty:

STEP House Program: Welcome and Acknowledgement

Please note:

Please include with your application (upload at end):

STEP Housing Program Application

Please provide all requested information and complete application fully – failure to do so will delay the admissions process or result in denial.

PERSONAL INFORMATION

CURRENT STATUS

PERSONAL SUPPORT

**The STEP House Residency Program allows children 10 years of age or younger to spend the night in the houses. All other children are welcome to visit as long as proper documentation is given and visitation guidelines are followed.

ADDICTION & HEALTH HISTORY

EMPLOYMENT HISTORY

EDUCATION

VETERAN STATUS

RECORD OF CHARGES AND CONVICTIONS

CONSENT FOR RELEASE OF INFORMATION

I understand that this information may be used for the following purposes:

Information obtained will remain confidential and only be shared in accordance with Federal Privacy Laws. Consent will remain effective for 90 days following completion of or termination from the Step Residence program.

Title VI Policy