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Stepping Stones Transitional Housing Application

Welcome to Stepping Stones Empowerment Center. This application is for men who are currently experiencing hard times and need safe, stable housing and support. Please answer as honestly as you can. Your information is confidential and will only be used to contact you and assess your eligibility for our program.

Full Name

*

Phone Number

*

Email Address

*

Best Way to Contact You

*

A

Phone call

B

Text message

C

Email

D

Any of the above

Date of Birth

*

Current City and State

*

What is your current living situation?

*

A

Homeless / sleeping outside

B

Staying in a shelter

C

Couch-surfing / staying with friends or family

D

Living in my own place but at risk of losing it

E

Leaving jail/prison or a program

F

Other

Please describe your current situation in your own words

*

When do you need housing by?

*

Do you have any source of income right now?

*

A

Full-time job

B

Part-time job

C

Benefits (SSI, SSDI, VA, unemployment, etc.)

D

No income at this time

E

Other

What kind of support are you most looking for right now? (Check all that apply)

*

Safe and stable housing

Help finding a job

Help with budgeting and money management

Life skills (time management, routines, communication)

Counseling or mental health support

Recovery / substance use support

Spiritual support / mentorship

Peer support / positive community

Other

What are your top 3 goals for the next 6-12 months?

*

Emergency Contact Name

*

Emergency Contact Phone Number

*

Consent & Agreement

*

I give Stepping Stones Empowerment Center permission to contact me by phone, text, or email about this application and support services.

I understand that my information will be kept confidential and used only to assess my eligibility and connect me with support.

Your Signature (Sign to confirm this application)

*

Signature