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Stepping Stone House
Admissions Application

Please complete the form in detail to help us serve you better.

Resident - General Information

First Name *

Middle Name

Last Name *

NickName

Phone *

Email *

Secured Information

Gender Identity *

Man
Woman
Transgender
Non-binary/non-conforming
Other
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Is your gender the same as the sex you were registered at birth? *

Yes
No
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Date of birth *

SSN/ITIN *

ID/CDL# *

Military ID #

What State issued your ID *

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Rhode Island
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
(Other)
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Marital Status *

Single (Never Married)
Married (Not Separated)
Separated
Divorced
Widowed
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Spouse's Name

Spouse's Phone #

Financial Information

Monthly Income 1 *

Income Source 1 *

Monthly Income 2 *

Income Source 2

Other Monthly Income *

Available Savings *

Expenses (Select all that apply) *

Cell Phone
Car Loan
Childcare
Debt/Other Loans
None
Other
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Total of Your Monthly Expenses *

Emergency Information

Emergency Contact (First Name) *

Emergency Contact (Last Name) *

Emergency Contact (Phone #) *

Emergency Contact (Email Address) *

Emergency Contact's Relationship To You *

Secondary Contact (First Name)

Secondary Contact (Last Name)

Secondary Contact (Phone #)

Secondary Contact (Email Address)

Secondary Contact's Relationship To You

Medical Information

Do you have Medical Insurance? *

Yes
No
In Process of Getting
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Health Card #

Medical Insurance Provider

Medical Insurance Contact #

Do you have any allergies or dietary restrictions? (Provide details below) *

List Medications *

Do you have any chronic medical issues we should be concerned about? (Please explain) *

Do you have any special medical equipment? *

Resident Suitability Questionnaire

Can you walk independently? *

Yes
No
Sometimes
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If No or Sometimes Explain

Can you participate in household cleaning and chores? *

Yes
No
Sometimes
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If No or Sometimes Explain

Can you bath and dress yourself? *

Yes
No
Sometimes
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If No or Sometimes Explain

Do you bath every day? *

Yes
No
Sometimes
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If No or Sometimes Explain

Do you have any issues with bladder control? *

Yes
No
Sometimes
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If No or Sometimes Explain

Are you on Probation or Parole? *

Yes
No
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Probation/Parole Officer Name

CDC #

Probation/Parole Officer Contact #

Probation/Parole End Date

Do you smoke? *

Yes
No
Sometimes
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If YES or Sometimes Explain

Are you recovering from any addiction that we should be aware of? *

Yes
No
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If YES Explain

What time do you normally go to bed? *

Do you have any regular medical appointments? (please explain) *

What are your favorite foods? *

List Activities you enjoy doing *

List concerns you may have living with a roommate? *

Do you work or volunteer anywhere? (Please explain) *

List ANYTHING else we should know or be concerned about *

The information I have provided above is true and accurate to the best of my knowledge. I understand that if I have not provided true and accurate information that it will be grounds for removal from the home.

Application Signature *

Clear

Application Submission Date *

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