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Certain Steps Program Application
Housing application
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* Indicates required question
Name
*
Your answer
Phone number
*
Your answer
Email address
Your answer
Sobriety Date
*
MM
/
DD
/
YYYY
Drug(s) of choice
Your answer
Do you currently have a sponsor and/or working a 12 step program?
Yes
No
Ar
e you currently in Treatment? If so where?
Your answer
Present employer or source of income
Your answer
What shift do you work?
Your answer
Do you own a vehicle that you will be parking at the residence??
Yes
No
Maybe
Clear selection
Are you currently on probation or parole?
Yes
No
Clear selection
Have you ever been convicted of a crime where you are required to register your address?
Yes
No
Clear selection
What medications are you currently taking?
Your answer
Emergency Contact information
*
Name and phone number
Your answer
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