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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 *

Is your gender the same as the sex you were registered at birth? *

Date of birth *

SSN/ITIN *

ID/CDL# *

Military ID #

What State issued your ID *

Marital Status *

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) *

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? *

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? *

If No or Sometimes Explain

Can you participate in household cleaning and chores? *

If No or Sometimes Explain

Can you bath and dress yourself? *

If No or Sometimes Explain

Do you bath every day? *

If No or Sometimes Explain

Do you have any issues with bladder control? *

If No or Sometimes Explain

Are you on Probation or Parole? *

Probation/Parole Officer Name

CDC #

Probation/Parole Officer Contact #

Probation/Parole End Date

Do you smoke? *

If YES or Sometimes Explain

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

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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