Apply for Housing

Small Steps Home Care Application

Please complete the application below as fully as you can. Your answers help us understand your needs and whether our shared living community is the right fit for you.

Questions? Call (713) 447-4024

Applicant Information

Date

Full name

Date of birth

Age

Phone number

How would you like to be contacted?

Gender

Who is completing this form?

Emergency Contact

Name

Relationship

Phone number

Current Situation

Current living situation

Referral source

Medical & Health

Please share any medical history you feel is relevant

This is open-ended — include anything that helps us understand your needs.

Are you currently receiving any mental health services?

Do you have any disabilities?

Any mobility needs?

Do you currently have a home health care provider?

Additional Information

Are you a veteran?

Do you smoke?

Substance use history

Are you currently on parole or probation?

Do you have any pending charges?

Are you a current sex offender, or subject to any residency restrictions?

Do you have a pet or service animal?

Small Steps complies with all applicable federal, state, and local fair housing laws regarding service animals and emotional support animals. Additional documentation may be required.

Room Preference

Preferred room type

Acknowledgements

Shared living notice. Small Steps Home Care is a shared living community. Residents live together in a shared home with common spaces.

Independent living notice. We are independent living. Each resident must be able to independently perform all activities of daily living.

Not a medical care provider. I understand and agree that Small Steps is a housing program. We do not provide medical care, personal care, supervision, or assistance. Each resident is responsible for managing their own personal care, medical needs, medications, transportation, and daily living tasks.

I understand and agree that Small Steps Home Care is a housing program and does not provide medical care, personal care, supervision, or assistance.I understand that I am responsible for managing my own personal care, medical needs, medications, transportation, and daily living tasks.I am comfortable participating in shared household chores and contributing to the upkeep of the home.