Step 1, Inc. a Men S Transitional Living/Treatment Home

Step 1, Inc. “A Men’s Transitional Living/Treatment Home” 1015 N. Sierra Street Reno, N.V. 89503 Phone & Fax (775) 329-9830

Name ______Date ______Date of birth ______Age ______SS# ______BACK # ______

Race: ______Ethnicity ______Prison Facility(If applicable) ___ Contact Person/ Case Worker ______Are you a Veteran Yes No Present Mailing Address ______How many children? ______Ages? ______Custody? ___ Yes ___ No Please fill out with as much detail as possible. Circle your preference of area to parole to: (If applicable): Reno or Las Vegas

Do you have any outstanding warrants for your arrest? ____ Yes ___ No

If yes, for what and where? ______

If not coming from prison, do you have any legal issues that may surface after coming into our program?______

What is your current offense/Sentence ______

*What was your Sentencing Date?______

Date of next Parole Board ______Expected Release Date ______

Parole/Probation Officer’s Name ______

Parole/Probation Officer Phone Number: ______

Date that your parole/probation expires: ______

Revised 05/13 1 Criminal History: Dates______Charge(s) Using/Drinking at the time of the offense? ______

How many write-ups or disciplinary problems? ______

Have you ever been convicted of a violent offense? ______If so, explain ______

Have you ever been convicted of a sexual offense? ______If so, explain what tier level rating you were given ______

Do you owe restitution or fines anywhere? ______If so, where and how much do you owe? ______

In prison, did you participate in: (please indicate specific dates, programs, etc.) Counseling Groups ______Special Training Programs Jobs you had while in prison ______

Job skills and experience ______Highest school grade completed (G.E.D. = 12) ______College level Classes ______

Revised 05/13 2 Have you ever lost a job due to substance abuse related behavior? (Like being in jail or prison)? ____ Yes ______No

Do you have a drug or alcohol problem? ____ Yes ______No

First Drug of Choice ______

Date of last use ______Age of 1st use ______

Method of use ______

AA/NA Attendance ____ Yes ______No Date of last attendance______

Second Drug of Choice ______

Date of last use ______Age of 1st use ______

Method of use ______

Any intravenous drug use? _____ Yes ____ No If yes, when ______

Prior Drug/Alcohol Treatment ____ Yes ____ No

Where ______When ______Was the treatment completed successfully? _____ Yes ______No

What was your longest period of drug/alcohol abstinence? From ______To ______

What do you attribute this period of abstinence to?

Revised 05/13 3 Have you ever developed a tolerance to any drug? ______Yes ______No (Meaning, have you ever had to drink/use more to get the same effect you got in the beginning of your addiction)?

Have you ever tried to control your drug/alcohol problem unsuccessfully? ____ Yes _____ No If yes, how? ______

What is your longest period of sobriety OUTSIDE of a controlled environment? ______

Medical / Psychological

Medical or psychological problems? (past and/or current) ______Have you EVER been diagnosed with any mental illness? What Year Diagnosis Current Medications ______Past Medications ______

Date of last TB test ______Results ______To be considered for acceptance into the Step 1 program, you must have the following items confirmed by your caseworker:  Current (TB) results.  Birth Certificate & Social Security Card on I-file. Once you have a bed date, YOU MUST COME DIRECTLY TO STEP 1 WITH NO STOPS IN BETWEEN! We will send you to P & P once you arrive at Step 1.

Have you ever participated in a transitional/residential facility or similar program? ___ Yes ____ No If yes, what program, when and where? ______How long did you stay? ______Reason for leaving ? ______

Revised 05/13 4 HAVE YOU EVER LIVED AT STEP 1 ?

IF YOU DO NOT ANSWER THE FOLLOWING THREE QUESTIONS, YOU WILL AUTOMATICALLY BE DISQUALIFIED!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

1. Why are you considering Step 1, Inc. as part of your release program? 2. What is your concept of Spirituality? 3. What is your opinion regarding AA/NA recovery? (Explain All of the above questions on a separate sheet of paper ).

Besides Step 1, Inc., do you have alternative programs that you are considering? If so, what are they? ______Do you have family / significant others in Nevada? ____ Yes ____ No (if yes, please circle the area) Southern Northern

Please describe these family members or significant others:

NAME RELATIONSHIP PHONE NUMBER 1. ______2. ______3.______4.______5. EMERGENCY CONTACT: (MUST HAVE AT LEAST ONE NAME & #) ______

I state that the above statements are true to the best of my knowledge.

Signed ______Date______

Revised 05/13 5