STEP2 Application Form

  • STEP2 Application Form

    Thank you for your interest in our treatment program. We’re here to support you on your path to recovery and are committed to walking alongside you every step of the way. Please complete this form in its entirety. Once submitted, a STEP2 staff member will reach out to schedule an assessment. Please print your completed Application Form and bring it with you to your assessment.

  • GENERAL INFORMATION

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  • Sex
  • Is this your legal name?
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  • Do you have health insurance?
  • Is it okay to leave a voice message?
  • Are you a U.S. citizen?
  • Are you a veteran?
  • Race:
  • Ethnicity:
  • Format: (000) 000-0000.
  • Have you been in a controlled environment for any amount of time in the past 30 days?
  • If yes, please indicate the type of controlled environment:

  • FAMILY/SOCIAL INFORMATION

  • Marital/Relationship Status:
  • Are vou satisfied with your relationship status?
  • What has been your usual living arrangements (for the past 3 years)?
  • Are vou satisfied with your living arrangement?
  • Are any of your children living with someone else due to a child protection order?
  • Do you currently live with anyone who has alcohol problems?
  • Do you currently live with anyone who uses non-prescribed drugs?
  • Do you have a history of alcohol or substance use in your family? (Parents or siblings)
  • With whom do you spend most of your free time?
  • Are vou satisfied spending your free time this way?
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  • As a child did you experience any of the following?
  • How troubled or bothered have you been in the past 30 days by family problems?
  • How troubled or bothered have you been in the past 30 days by social problems?
  • How important to you now is treatment or counseling for family problems?
  • How important to you now is treatment or counseling for social problems?

  • EDUCATION & EMPLOYMENT INFORMATION

  • Training or technical education completed?
  • Do you have a valid driver's license?
  • Do you have an automobile available for use?
  • Do you have transportation available?
  • What is your current employment status? Choose "Not in Labor Force" if you are a homemaker, disabled, incarcerated, or other.
  • Does someone contribute to the majority of your support?
  • Usual employment pattern for the past 3 years?
  • How troubled or bothered have you been by these employment problems in the past 30 days?

  • MEDICAL INFORMATION

  • Do you have any chronic medical problems which continue to interfere with your life?
  • Are you taking prescribed medications on a regular basis for a physical problem?
  • Do you receive a pension for a physical disability?
  • Have you ever sustained a head injury and/or lost consciousness?
  • If female, are you pregnant?
  • How troubled or bothered have you been by these medical problems in the past 30 days?
  • How important to you now is treatment for these medical problems?

  • MENTAL & EMOTIONAL HEALTH INFORMATION

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  • How much have you been troubled by these psychological or emotional problems in the past 30 days?
  • How important to you now is treatment for these psychological problems?
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  • LEGAL INFORMATION

  • Was this admission prompted or suggested by the Criminal Justice System? (Judge, Probation/Parole Officer, etc.)
  • Are you on Probation or Parole?

  • How many times in your life have you been arrested and charged with the following crimes? Please indicate the number of times in the box next to each crime listed.

  • How many times in your life have you been charged with the following?

  • Are you presently awaiting charges, trial, or sentencing?
  • How serious do you think your present legal problems are? Exclude civil problems.
  • How important to you now is counseling or referral for these legal problems?

  • SUBSTANCE INFORMATION

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  • ADDITIONAL SUBSTANCE INFORMATION

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  • How troubled or bothered have you been in the past 30 days by alcohol problems?
  • How troubled or bothered have you been in the past 30 days by drug problems?
  • How important for you now is treatment for alcohol problems?
  • How important for you now is treatment for drug problems?

  • Finding Your ACE (Adverse Childhood Experience) Score

    Please checkmark next to each ACE category that you experienced before your 18th birthday (as a child and teen). If the answer is no, please leave blank.

  • Our relationships and experiences--even those in childhood--can affect our health and well-being. Difficult childhood experiences are very common. Please tell us whether you have had any of the experiences listed below, as they may be affecting your health today or may affect your health in the future. This information will help you and your provider better understand how to work together to support your health and well-being.

    Based on: https://www.acesaware.org/wp-content/uploads/2022/07/ACE-Questionnaire-for-Adults-Identified-English-rev.7.26.22.pdf

  • Do you believe that these experiences have affected your health?

  • MENTAL HEALTH SCREENING - MHS

  • Instructions: In this program, we help people with various problems. This includes helping people with emotional problems, which are within our scope of practice. Our program would like to help you with any emotional problems you may have, and we can do this only if we are aware of the problems. Any information you provide to us on this form will be kept at STEP2 and will only be released to an outside person or agency with your permission. If you do not know how to answer these questions, call our office at 775-787-9411 and we will assist you.

    Please note that each item refers to your entire life history, not just your current situation. This is why each question begins, "Have you ever?"

  • 1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an emotional problem?
  • 2. Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems?
  • 3. Have you ever been advised to take medication for anxiety, depression, and/or hearing voices, or for any other emotional problem?
  • 4. Have you ever been seen by a mobile crisis team or in an emergency room or been hospitalized for mental or emotional reasons?
  • 5. During times when you are clean and sober, have you ever heard voices no one else could hear or seen objects or things that others could not see?
  • 6. Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, or had trouble concentrating and making decisions?
  • Have you had thoughts of killing yourself or wanting to die in the last 30 days?
  • Have you ever attempted to kill yourself?
  • 7. Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example: warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot, or stabbed?
  • 8. Have you experienced any intense fears that interfere with your life? For example: of heights, insects, dirt, social events, being in a crowd, being alone, being in places where it may be hard to escape or get help?
  • 9. Have you ever given in to an aggressive or angry urge or impulse that harmed yourself or others or destroyed property?
  • Were you under the influence?
  • 10. Have you ever experienced legal problems associated with your sexual interests, your sexual activities, or your choice of sexual partner?
  • 11. Have you ever felt that people have something against you without other people saying so directly, or have you ever felt that someone, some group, or something is trying to influence your thoughts or behaviors?
  • 12. Have you ever had a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling your eating? For example: by repeatedly dieting or fasting, avoiding foods, food rituals, intense exercise, binge eating, using enemas or laxatives, or forcing yourself to throw up?
  • 13. Have your relatives/friends/coworkers ever considered any of your beliefs strange or unusual?
  • 14. Have you ever had spells or attacks when you suddenly felt anxious, frightened, and uneasy to the extent that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach was upset, and you felt dizzy or unsteady as if you would faint?
  • 15. During times when you are clean and sober, have you ever had a period of time when you were so full of energy that your ideas came very rapidly, when you talked nearly non-stop, when you moved quickly from one activity to another, when you needed little or no sleep, and/or believed you could do almost anything?
  • 16. Have you ever had a persistent, lasting thought or impulse to do something over and over that caused you distress and interfered with normal routines, work, or social relations? For example: counting things, checking and rechecking things, hoarding, arranging things, washing and rewashing your hands, praying, repeating words or numbers, or sticking to a rigid schedule of daily activities that cannot change?
  • 17. Have you ever lost large sums of money through gambling, shopping, giving money to other people, or just "blowing it," or have you had problems at work, in school, or with your family and friends due to your spending?
  • 18. Have you been told by teachers or others that you have difficulty learning or a learning disability?
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