Admissions Form

Step 1 Recovery Admission Form

First Name

Last Name

Phone Number

Date of Birth

Age

Social Security Number

BACK#

Race

If White, Select Ethnicity

Prison Facility (If Applicable)

Contact Person/Case Worker

Are you a Veteran?

yes no

Branch

Present Mailing Address

How many children do you have?

What are their ages?

Do you have custody?

yes no

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?

yes no

If yes, what legal issues?

What is your current offense/sentence?

Sentencing Date

Date of Next Parole Board

Expected Release Date

Date Your Parole/Probation Expires

Parole/Probation Officer's Name

Parole/Probation Officer's Phone Number

Client Initial

Dates of Prison Attendance

Criminal History

Were you using/drinking at the time of offense?

yes no

Do you have any write-ups or disciplinary problems?

yes no

If yes, how many and why?

Have you ever been convicted of a violent offense?

yes no

If so, explain:

Have you ever been convicted of a sexual offense?

yes no

If so, what tier level rating were you given?

Do you owe restitution or fines anywhere?

yes no

If so, where?

How much do you owe?

In prison, did you participate in:

Counseling Groups Special Training Programs Jobs in Prison

Please indicate specific dates, programs, etc. you were involved in:

List any job skills and experience:

Highest School Grade Completed (G.E.D.=12)

Have you taken any college level classes?

yes no

If so, please list the classes taken:

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? (Just because you aren't drinking or using right now, does not mean you don't have a problem anymore).

yes no

Client Initial

First Drug of Choice

Date of Last Use

Age of 1st Use

Method of Use (Check the one you did most often)

Oral Smoke Nasal I.V.

Any intravenous drug use?

yes no

Have your had prior drug or alcohol treatment?

yes no

If yes, where?

When?

Was the treatment completed successfully?

yes no

What was your longest period of drug/alcohol abstinence (not using anything)?

What do you attribute this period of abstinence to?

Have you ever developed a tolerance to any drug (meaning, have you ever had to drink/use more to get the same effect you got in the beginning of your addiction)?

If yes, how?

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?

Do you have any medical problems?

yes no

If yes, please indicate if current or past condition:

Have you EVER been diagnosed with a Mental Health Disorder?

yes no

If yes, what year?

What was the diagnosis?

Current Medications

Past Medications

Please Note: If you have ever had a M.H. Diagnosis, you will be required to obtain a Mental Health Assessment within one week of admission at Step 1. Should you fail to complete this task, you will be asked to leave the program. No exceptions! If you understand the above statements check the box below.

Client Initial

Date of Last TB Test

Results

Have you received a COVID-19 vaccination?

yes no

What kind?

Moderna Pfizer Johnson&Johnson

Date of 1st Vaccination

Date of 2nd Vaccination

If no, are you willing to be Vaccinated?

yes no

To be considered for acceptance into the Step 1 program, you must have the following items confirmed by your caseworker: • Current (TB) results. • COVID Vaccination record (If applicable) • Birth Certificate & Social Security Card on I-file. Once you have a bed date, YOU MUST COME TO STEP 1 DIRECTLY FROM THE P & P OFFICE, WITH NO STOPS IN BETWEEN! IF THERE IS A DELAY, WE MAY NOT ACCEPT YOU. PLEASE CALL TO KEEP US INFORMED! If you understand the above statements check the box below.

Client Initial

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?

HAVE YOU EVER LIVED AT STEP 1?

yes no

IMPORTANT: Why are you considering the Step 1, Inc. program?

What is your concept of Spirituality?

What is your opinion regarding AA/NA recovery?

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 so, what area?

Southern Northern

Please describe these family members or significant others:

Emergency Contact (must have at least one name)

Emergency Contact (must have at least one phone number))

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

Client Initial

The Step 1 Mission

Serving the community by providing transitional housing and supportive services to adult men who have been diagnosed with a substance use disorder and who seek to re-enter society as self-sufficient, responsible fathers, individuals and citizens.

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© Copyright 2018. This website was supported in whole or in part by the Nevada Division of Public and Behavioral Health, Substance Abuse Prevention and Treatment Agency (SAPTA) through State General Funds and/or the SAPT Block Grant for the Substance Abuse and Mental Health Services Administration (SAMHSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. DHHS, SAMHSA, or the State of Nevada.