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  • SteadyStep Reentry Program Referral Form

  • Please complete all sections of the referral application.

  • Charges:

  • Rows
  • Last Infraction Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:
  • Pronouns:
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • U.S. Citizen:
  • Mental Capacity – Able to make sound decisions independently:
  • Mental Health Diagnosis:
  • Level of Care:
  • Documentation Available at Release (check all that apply):
  • Veteran Status:
  • Disabled:
  • Mobility Aids Used (check all that apply):
  • Requires Handicap Accessible Housing:
  • Can comfortably use stairs multiple times daily (15+ steps):
  • SSI/SSDI Status:
  • Sexual Offense Conviction Status:
  • Active Recovery from Opioids/Drugs/Alcohol:
  • Are you currently using medications for opioid use disorder (methadone, buprenorphine, or naltrexone )
  • Release Type:
  • Types of jobs the individual is willing to work:
  • How will the individual be making the initial payment?
  • Date first and second month's program fee can be paid:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date client needs placement:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Requested 3rd Party Support Services (check all that apply):

  • Acknowledgements

  • By submitting this referral, you confirm and agree that the individual being referred is an independent adult who is able to manage their own daily living needs without assistance. SteadyStep LLC provides independent housing only and does not offer personal care, medical support, or custodial services. Referrals or supportive service providers are independent, unaffiliated organizations and operate separately from SteadyStep LLC.
  • Acknowledgement Confirmation
  • Date Submitted:
     - -
    2 digit month, 2 digit day, 4 digit year

  • All completed applications will go to : Info@steadystep.org, Please allow our team 1–2 business days to review the referral and follow up. Each individual is evaluated on a case-by-case basis, and submission of an application does not guarantee placement.

  • Website: www.steadystep.org    Ph: (336)380-5852    Email: Info@steadystep.org
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