Step Up Housing Application

Provide full and complete answers to every question. If a question does not apply to you answer "N/A". Incomplete or misleading information will influence your apllication and/or stay in the program.

First Name

Middle Name

Last Name

Current Address

Town/City

Postal Code

Phone number with Area Code

Email Address

Age

Date of Birth MM/DD/YYYY

What is your current situation? Please be as specific as possible.

Why are you applying to the Step-Up Program?

I am currently...

What is your source of income?

Are you curently on parole?

Yes

If yes, include the contact information of your parole officer.

Are you currently taking prescribed medications?

Yes

If yes, why? Please provide details.

Do you have a history of drug or alcohol abuse?

Are you willing to take a drug test?

Yes

Are you willing to attend life skills courses while in the Step-Up Program?

Yes

List your SHORT-TERM GOALS (to be completed within 3-6 months) Please be specific.

List your LONG-TERM GOALS (to be completed within 1-2 years) Please be specific.

STEP UP HOUSING APPLICATION

Step Up Housing Application