Call today: 800-545-9031
Services
Detox and Residential
Intensive Outpatient
Sober Living
Medication-Assisted Therapy (MAT)
PICC Line Program
Locations
Bowling Green
E-town Crowne Pointe
E-town Woodland Dr.
London
Nicholasville
Paducah
About Us
The Stepworks Story
CARF Accreditation
Accepted Insurances
Frequently Asked Questions
Meet Our Team
Careers
Contact Us
Contact Us
Medical Records Request
Referral Info
Blog
Blog/Media
Doctor’s Notes by Tom Ingram
Stepworks Sober Living Home Resident Application
Full Name (First, Middle, Last)
*
Date of Birth
*
Month
Day
Year
Social Security Number
*
Current Address
*
Home of Record
*
ID/Driver's License (#/State)
*
Verified Initials (House Manager/Administrator)
Emergency Contact
*
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Present Employer
*
Current Supervisor
*
Employer Phone Number
*
Employer Address
*
Have you ever been convicted of a crime?
*
Yes
No
If yes, please explain
Are you currently in the legal system?
*
Yes
No
If yes, please explain
List any current Probation/Parole Officers and their contact numbers
What are your drugs of choice (please explain)
*
Have you ever been to a treatment facility?
*
Yes
No
If yes, please explain
Please list any medications you are currently taking and why
Sobriety Date (If applicable)
Month
Day
Year
Do you have a sponsor?
*
Yes
No
Sponsor's name and contact numbers
Have you ever been in a recovery house, halfway house, or similar facility?
*
Yes
No
If yes, please explain
Applicant Signature
*
Date
*
Month
Day
Year
Staff Signature
Date
Month
Day
Year
Services
Detox and Residential
Intensive Outpatient
Sober Living
Medication-Assisted Therapy (MAT)
PICC Line Program
Locations
Bowling Green
E-town Crowne Pointe
E-town Woodland Dr.
London
Nicholasville
Paducah
About Us
The Stepworks Story
CARF Accreditation
Accepted Insurances
Frequently Asked Questions
Meet Our Team
Careers
Contact Us
Contact Us
Medical Records Request
Referral Info
Blog
Blog/Media
Doctor’s Notes by Tom Ingram
If you applied to Stepworks Sober Living between April 15 and June 13, 2023, please call
1-888-627-0030
for important information.