Request for Information

Next Steps Housing Intake Form

Welcome to the Next Steps Housing intake wizard. we would like to collect some basic information about you to prepare for your interview.
Click next to begin!

General

Tell us about yourself
What is your first name as it appears on your ID?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
If you go by nickname, please provide it. 
Client nickname
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Contact Information

How can we reach you?

What is your email address?
Client email
Phone number where we can reach you?
Client phone
Current street address if applicable:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Client Referral Source 

How did you hear about us?
Dropdown

Occupancy

What date do you plan to be admitted on?
Date
What is the estimated length of stay?
Text field
When do you plan to be discharged?
Date

Employment

Tell us about your current employment status. At least one answer will have to be provided. If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

House Rules

Please read the house rules and initial each rule to acknowledge that you have read it, understand it, and agree to comply with all house rules. 
By initialing/signing, I acknowledge agreement to the terms stated, and hereby waive my right(s) to normal due process afforded by local landlord- tenant laws.  
 Billing Policy
Initials Text field Rent is $165.00 per week for a double occupancy room or $200.00 per week for a single occupancy room. 
Initials Text field Residents are required to pay a security deposit before moving into the house. The amount of the deposit is equal to one week's rent.
Initials Text field Upon leaving the house, the security deposit will be refunded, minus any charges for damages, unpaid fees, or other outstanding costs. A final inspection will be conducted before the deposit is refunded.
Initials Text field

Any necessary deductions from the deposit will be itemized and documented.

 

House Rules Continued 

Zero Tolerance Policies:

Initials Text field The use of any drugs or alcohol at any time are grounds for immediate eviction. 
Initials Text field The possession and/or distribution of any drugs or alcohol are grounds for immediate eviction. 
Initials Text field No smoking in any room of the house is permitted at any time and is grounds for immediate eviction. 
Initials Text field Stealing which includes taking other people's food, is grounds for immediate eviction. 
Initials Text field Damaging the house or any contents of the house is grounds for immediate eviction. 
Initials Text field Any form of confrontation: physical, verbal, or threatening behavior are grounds for immediate eviction. 
Initials Text field Any criminal activity of ANY kind is grounds for immediate eviction. 

House Rules Continued 

Household responsibilities and conduct

Initials Text field Thermostat is to be adjusted by the House Manager only.
Initials Text field Washer & Dryer -- Be courteous. Clean dryer lint screen before and after every use and do not leave clothes unattended in the washer/dryer.
Initials Text field Chores are required to be completed daily. The House Manager is responsible for chore assignment and completion. Failure to complete assigned chore can/will result in fine/eviction.
Initials Text field A good General Clean-up of all areas inside & outside the home is required at all times. 
Initials Text field Beds are required to be made upon awakening. Respective areas are to be kept neat, clean and picked up at all times. NO SLOBS!
Initials Text field Turn off lights, TV’s, Radio’s, Fans, etc., when not in use. Exterior doors are required to be locked when entering/exiting; no exceptions!
Initials Text field Residents are required—at all times—to wear appropriate dress in common areas.
Initials Text field Sleeping in common areas is prohibited.
Initials Text field Kitchen—Appliances, Counter-tops, Utensils, Dishes, Pots, Pans, etc. will be cleaned and returned to their respective place (immediately) after each use.
Initials Text field Refrigerator—Mark food/leftovers with Name/Date when initially placed in the refrigerator.


House Rules Continued 

Good Neighbor Policies 

Initials Text field Residents are expected to observe quiet hours between 10:00 PM and 7:00 AM to minimize noise to the surrounding neighborhood. This includes keeping music, TV, and conversations at a respectful volume, particularly in shared spaces and bedrooms.
Initials Text field Residents are responsible for keeping the area around the house clean and free of litter. This includes disposing of trash in designated bins and picking up any litter outside the house.
Initials Text field Residents should maintain courteous and respectful behavior around the neighborhood.

 Overnight Passes

Initials Text field Overnight passes are required if you are staying away from the house during your residency
Initials Text field Passes should be requested 48 hours in advance. 

Your story

 

What is the substance that you are recovering from?

Client substances of choice

 

Tell us a little about your story, what has brought you to us, and what you are looking for. 

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