<p> Step 1, Inc. “A Men’s Transitional Living/Treatment Home” 1015 N. Sierra Street Reno, N.V. 89503 Phone & Fax (775) 329-9830</p><p>Name ______Date ______Date of birth ______Age ______SS# ______BACK # ______</p><p>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</p><p>Do you have any outstanding warrants for your arrest? ____ Yes ___ No</p><p>If yes, for what and where? ______</p><p>If not coming from prison, do you have any legal issues that may surface after coming into our program?______</p><p>What is your current offense/Sentence ______</p><p>*What was your Sentencing Date?______</p><p>Date of next Parole Board ______Expected Release Date ______</p><p>Parole/Probation Officer’s Name ______</p><p>Parole/Probation Officer Phone Number: ______</p><p>Date that your parole/probation expires: ______</p><p>Revised 05/13 1 Criminal History: Dates______Charge(s) Using/Drinking at the time of the offense? ______</p><p>How many write-ups or disciplinary problems? ______</p><p>Have you ever been convicted of a violent offense? ______If so, explain ______</p><p>Have you ever been convicted of a sexual offense? ______If so, explain what tier level rating you were given ______</p><p>Do you owe restitution or fines anywhere? ______If so, where and how much do you owe? ______</p><p>In prison, did you participate in: (please indicate specific dates, programs, etc.) Counseling Groups ______Special Training Programs Jobs you had while in prison ______</p><p>Job skills and experience ______Highest school grade completed (G.E.D. = 12) ______College level Classes ______</p><p>Revised 05/13 2 Have you ever lost a job due to substance abuse related behavior? (Like being in jail or prison)? ____ Yes ______No</p><p>Do you have a drug or alcohol problem? ____ Yes ______No</p><p>First Drug of Choice ______</p><p>Date of last use ______Age of 1st use ______</p><p>Method of use ______</p><p>AA/NA Attendance ____ Yes ______No Date of last attendance______</p><p>Second Drug of Choice ______</p><p>Date of last use ______Age of 1st use ______</p><p>Method of use ______</p><p>Any intravenous drug use? _____ Yes ____ No If yes, when ______</p><p>Prior Drug/Alcohol Treatment ____ Yes ____ No </p><p>Where ______When ______Was the treatment completed successfully? _____ Yes ______No</p><p>What was your longest period of drug/alcohol abstinence? From ______To ______</p><p>What do you attribute this period of abstinence to?</p><p>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)? </p><p>Have you ever tried to control your drug/alcohol problem unsuccessfully? ____ Yes _____ No If yes, how? ______</p><p>What is your longest period of sobriety OUTSIDE of a controlled environment? ______</p><p>Medical / Psychological </p><p>Medical or psychological problems? (past and/or current) ______Have you EVER been diagnosed with any mental illness? What Year Diagnosis Current Medications ______Past Medications ______</p><p>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. </p><p>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 ? ______</p><p>Revised 05/13 4 HAVE YOU EVER LIVED AT STEP 1 ? </p><p>IF YOU DO NOT ANSWER THE FOLLOWING THREE QUESTIONS, YOU WILL AUTOMATICALLY BE DISQUALIFIED!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!</p><p>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 ).</p><p>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</p><p>Please describe these family members or significant others:</p><p>NAME RELATIONSHIP PHONE NUMBER 1. ______2. ______3.______4.______5. EMERGENCY CONTACT: (MUST HAVE AT LEAST ONE NAME & #) ______</p><p>I state that the above statements are true to the best of my knowledge.</p><p>Signed ______Date______</p><p>Revised 05/13 5</p>