Steppingstone Application

Name:*
Date of Birth*
MM slash DD slash YYYY
Current Address
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email
Have you applied to Steppingstone in the past?*
- Yes
- No
If so, when?
Personal Information
Gender*
- Male
- Female
Marital Status*
- Single
- Married
- Other
Do you have any children?*
- Yes
- No
If you have children, what are their ages?
Are you currently pregnant?
- Yes
- No
Please list all medication you are currently taking.
Education
Education (check all that apply)*
- Some High School
- High School Diploma
- GED/HiSET
- Trade School
- Some College
If you did not complete high school, what was the last grade you completed?
If you are currently in school, where?
If you are under the age of 18, who is your legal guardian?
Guardian's Name
Guardian's Address
Street Address City State / Province / Region ZIP / Postal Code
Employment
Are you currenlty employed?*
- Yes
- No
Full-time or Part-time?
- Full-time
- Part-time
Where?
Have you ever been employed?
- Yes
- No
If so, where?

8240 St. Charles Rock Road
St. Louis, MO 63114
(314) 427-3755

5100 Noland Road
Kansas City, MO 64133
(816) 356-0187

Community-Based Programs in St. Louis
Jefferson City Office
Dexter Office
Franklin County Office

Personal Information