Name: ________________________________________________________________________________________

LAST FIRST M.I.

Date of Birth: ______/______/______
(    ) MALE (     ) FEMALE
SSN______-_____-_______

CURRENT ADDRESS: _______________________________________________________________________

TELEPHONE: ______________________________________________________________________________

HOME WORK CELL

ARE YOU A RECOVERING: ( ) ALCOHOLIC ( ) DRUG ADDICT

Have you been in substance abuse treatment, either in or out-patient, within the last 3 years? List the name of each program, the dates you attended, if you graduated, or if you were discharged explain why?

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Are you currently in a self-help recovery program: ( ) AA ( ) NA

How many meetings do you attend weekly? ____________________________________

Do u have a sponsor? ( ) YES ( ) NO If No, why not? _______________________

What is your source of income? ( ) Employment ( ) Disability $__________per month

Other (explain) __________________________________________________________________________________________

Employer: Name, Address, Phone ______________________________________________________________________

Job Description: _______________________________Weekly Net Income; $ ____________How Long?:____________

List source and amount of other weekly income: ______________________________________

Marital status: ( ) Single ( ) Married ( ) Divorced

Do you take prescription medication ( ) YES ( ) NO If �YES� Please List

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Are you or will you be on a drug replacement program (i.e. Methadone, Suboxone)? ( ) YES ( ) NO

Please list two Emergency Contacts:

_______________________________________________________________________________________________________

NAME TELEPHONE RELATIONSHIP

_______________________________________________________________________________________________________

NAME TELEPHONE RELATIONSHIP

List your 2 most recent residences:

_______________________________________________________________________________________________________
NAME/ADDRESS OF HOUSE DATES REASON FOR LEAVING

_______________________________________________________________________________________________________

NAME/ADDRESS OF HOUSE DATES REASON FOR LEAVING

ARE YOU CURRENTLY ON PROBATION/PAROLE? ( ) YES ( ) NO

_______________________________________________________________________________________________________

PROBATION OFFICER’S NAME  & PHONE NUMBER

PLEASE NOTE THAT:

Steps to Solutions House will require immediate discharge of any resident who is found by majority house vote and or decision of the house manager to be:

1. Using alcohol or drugs
2. In default of weekly house payment share of expenses
3. Guilty of disruptive behavior

CODE OF RESPONSIBILITY

• A RESIDENT OF STEPS TO SOLUTIONS, INC. IS NOT A TENANT BUT RATHER A MEMBER OF A SOBER LIVING COMMUNITY.
• SUCH A RESIDENT IS NOT ENTITLED TO ANY OF THE RIGHTS AND PROTECTION PURSUANT OF A TENANT UNDER MASSACHUSETTS GENERAL LAW.
• STEPS TO SOLUTIONS, INC. REQUIRES A $150 DEPOSIT TO BE PAID AT THE TIME OF YOUR ACCEPTANCE. ALONG WITH YOUR FIRST WEEK OF RENT
• THIS IS A NON-REFUNDABLE DEPOSIT AND YOUR SHARE OF HOUSE FEES ARE DUE WITHOUT EXCEPTION, ON EACH FRIDAY.
  • SINGLE ROOMS ARE $180 P/W
  • DOUBLE ROOMS ARE $160 P/W
  • TRIPLE ROOMS ARE $140 P/W
• PERSONAL TV IN ROOM IS A $10 CHARGE A MONTH, PERSONAL A/C IS $50 A MONTH DUE THE FIRST OF EACH MONTH WITH 2 MONTHS DUE UPON ACCEPTANCE TO PROGRAM
• STEPS TO SOLUTIONS, INC. IS NOT RESPONSIBLE FOR ANY PERSONAL BELONGINGS OF MEMBERS
• MUST ATTEND WEEKLY HOUSE MEETING EVERY WEEK (NO EXCEPTIONS)
• MUST SUBMIT TO THREE (3) LABORATORY URINE SCREENS EACH WEEK
• MUST SUBMIT TO RANDOM QUICK CUP DRUG TESTS AT STAFF’S DISCRETION

I have read and understand this application; I am applying to become a member of the Steps to Solutions Community and not an officially recognized tenant of a property in the Commonwealth of Massachusetts. I agree to abide by the rules of the house as stated above.

By signing below I certify the information I provide to be correct and that I understand the condition of my residency as stated in the house rules a copy of which I was provided.

DATE: ____________________________ SIGNATURE:_________________________________________