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
Who referred you to STEP2?
Date

MonthDayYear
Last name
First
Middle
Age
Sex

MFOther
Is this your legal name?

YesNo
If not, what is your legal name?
Former Name
Birth Date

MonthDayYear
Date
Social Security Number
Do you have health insurance?

YesNo
Insurance Carrier
Street Address
Years at Address
City
State
Zip Code
Phone Number
Birth City
Are you a U.S. citizen?

YesNo
Are you a veteran?

YesNo
If yes, which branch?
Race:

Alaska Native (Aleut, Eskimo, Indian)Black or African AmericanOther single raceAmerican Indian (Other than Alaskan Native)Native Hawaiian/other Pacific IslanderTwo or more racesAsianWhiteUnknown
Ethnicity:

Not of Hispanic originSouth AmericanPuerto RicanCentral AmericanDomincan RepublicOther specific HispanicCubanMexican
Permanent Contact:
Contact's Phone Number:
Have you been in a controlled environment for any amount of time in the past 30 days?

YesNo
If yes, please indicate the type of controlled environment:

JailPsychiatric TreatmentAlcohol/Drug Treatment ProgramMedical TreatmentOther
If yes, how many days in the past 30 days were spent in a controlled environment?
FAMILY/SOCIAL INFORMATION
Marital/Relationship Status:

MarriedRemarriedWidowedSeparatedDivorcedNever married
Are vou satisfied with your relationship status?

YesNoIndifferent
What has been your usual living arrangements (for the past 3 years)?

With sexual partner and child(ren)With sexual partner aloneWith children aloneWith parentsWith familyWith friendsAloneIn a controlled environmentHomeless
Are vou satisfied with your living arrangement?

YesNoIndifferent
How many children do you have in your household that are under the age of 18?
Are any of your children living with someone else due to a child protection order?

YesNo
If yes, please list child's name, age, and where they are currently living:
Do you currently live with anyone who has alcohol problems?

YesNo
Do you currently live with anyone who uses non-prescribed drugs?

YesNo
Who did you live with growing up?
Do you have a history of alcohol or substance use in your family? (Parents or siblings)

YesNo
If yes, please list who:
With whom do you spend most of your free time?

FamilyFriendsAlone
Are vou satisfied spending your free time this way?

YesNoIndifferent

Who have you have you expierenced serious problems getting along with?

	Past 30 days	Past 6 months	In lifetime
Mother
Father
Brothers/Sisters
Sexual Partner/Spouse
Children
Other Significant Family Member
Close Friends
Neighbors
Co-Workers

Did any of these people abuse you?

	Past 30 days	Past 6 months	As a child
Physically, including: Hit, Slap, Push, Shove, Kick, Punch, Held Down, Pinned, Choked
Sexually, including: Exposure, Threats, Unwanted Contact, Forced Contact
Verbally/ Emotionally, including: Screaming, Name Calling, Intimidation, Threats, Accusations

How many days in the past 30 days have you had serious conflicts with other people (not family)?
How troubled or bothered have you been in the past 30 days by family problems?

Not at allSlightlyModeratelyConsiderablyExtremely
How troubled or bothered have you been in the past 30 days by social problems?

Not at allSlightlyModeratelyConsiderablyExtremely
How important to you now is treatment or counseling for family problems?

Not at allSlightlyModeratelyConsiderablyExtremely
How important to you now is treatment or counseling for social problems?

Not at allSlightlyModeratelyConsiderablyExtremely
EDUCATION & EMPLOYMENT INFORMATION
Highest level of schooling completed:
Training or technical education completed?

YesNo
Do you have a valid driver's license?

YesNo
Do you have an automobile available for use?

YesNo
Do you have transportation available?

YesNo
What is your current employment status? Choose "Not in Labor Force" if you are a homemaker, disabled, incarcerated, or other.

Not in labor forcePart time (<35 hours)Full time (>35 hours)Unemployed - not sought employment in the past 30 daysUnemployed - sought employment in the past 30 daysUnknown
How long was your longest full time job?
Usual or last occupation?
Does someone contribute to the majority of your support?

YesNo
Usual employment pattern for the past 3 years?

Full timePart time (regular hours)Part time (irregular hours)StudentMilitary serviceRetired/disabledUnemployedControlled environment
How many days were you paid for working in the past 30 days? (include "under the table" work)
How many people depend on you for the majority of their food, shelter, etc.?
How many days have you experienced employment or school problems in the past 30 days?
How troubled or bothered have you been by these employment problems in the past 30 days?

Not at allSlightlyModeratelyConsiderablyExtremely
MEDICAL INFORMATION
How many times in your life have you been hospitalized for medical problems?
Do you have any chronic medical problems which continue to interfere with your life?

YesNo
If yes, what are the conditions?
Other conditions?
Are you taking prescribed medications on a regular basis for a physical problem?

YesNo
If yes, what medications are you taking?
Do you receive a pension for a physical disability?

YesNo
If yes, what is the disability?
If female, are you pregnant?

YesNoUnknown
How many days have you experienced medical problems in the past 30 days? (Include sickness andor physical health problems. Exclude alcohol and/or drug induced problems.)
How troubled or bothered have you been by these medical problems in the past 30 days?

Not at allSlightlyModeratelyConsiderablyExtremely
How important to you now is treatment for these medical problems?

Not at allSlightlyModeratelyConsiderablyExtremely
MENTAL & EMOTIONAL HEALTH INFORMATION

During times when you are NOT under the influence of a substance:*

	Past 30 days	In lifetime
Do you struggle to remember recent events, recall conversations from a few days ago, or learn new information?
Have you ever felt that you are not in control of your ideas or thoughts?
Are your thoughts sometimes so strong that you can almost hear them?
Have you ever received special messages through advertisements or things around you?
Do you sometimes feel that strangers are out to get you?
Have you ever experienced times when you don't sleep for days but still have a lot of energy?
Have you had times when you are much more social, outgoing, or engaging in risky behaviors, or making very impulsive decisions?
Have you ever had suicidal thoughts?
Did you ever attempt to kill yourself?

In your lifetime, have you struggled to remember recent events, recall conversations from a few days ago, or learn new information?

YesNo
How many days in the past 30 days have you experienced these psychological or emotional problems?
How much have you been troubled by these psychological or emotional problems in the past 30 days?

Not at allSlightlyModeratelyConsiderablyExtremely
How important to you now is treatment for these psychological problems?

Not at allSlightlyModeratelyConsiderablyExtremely

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you:

	Yes	No
Have had nightmares about it or thought about it when you did not want to?
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your surroundings?
Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

LEGAL INFORMATION
Was this admission prompted or suggested by the Criminal Justice System? (Judge, Probation/Parole Officer, etc.)

YesNo
Are you on Probation or Parole?

YesNo
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.
Forgery:
Weapons Offense:
Drug charges:
Assault:
Arson:
Rape:
Prostitution:
Contempt of Court:
Homicide/Manslaughter:
Robbery:
Shoplifting, Vandalism:
Parole/Probation violation:
Burglary, Larceny, Breaking & Entering:
Restraining Order issue:
How many of these resulted in a conviction?
How many times in your life have you been charged with the following?
Disorderly Conduct:
Driving While Intoxicated:
Major Driving Violations (Reckless driving, no license, etc.):
How many total months have you been incarcerated in your life?:
Are you presently awaiting charges, trial, or sentencing?

YesNo
If yes, what for? If multiple charges, list the most severe.
In the past 30 days, how many nights have you spent in jail or prison? Include not being formally arrested.
In the past 30 days, how many days have you engaged in illegal activities for profit?
How serious do you think your present legal problems are? Exclude civil problems.

Not at allSlightlyModeratelyConsiderablyExtremely
How important to you now is counseling or referral for these legal problems?

Not at allSlightlyModeratelyConsiderablyExtremely
SUBSTANCE INFORMATION

For the "Past 30 days" column, indicate how many days you've used each substance in the past 30 days.*

	Past 30 days	Lifetime use (years)	Age at first use	Route of administration	Date of last use
Alcohol (any use at all - beer wine, liquor)
Alcohol (use to intoxication)
Heroin
Street Methadone (non-treatment)
Other Opiates/Analgesics (Opium / Demerol / Morphine)
Barbiturates (Yellow Jackets / Reds / Blues / Rainbows)
Benzodiazepines (Hypnotics / Demerol / Morphine)
Cocaine/Crack
Methampetamines / Amphetamines
Cannabis (Marijuana / Hashish)
Hallucinogens / Psycdelics (LSD / PCP / Mushrooms)
Bath Salts
Inhalants
More than one of the above substances per day (Include alcohol)

ADDITIONAL SUBSTANCE INFORMATION
How many times in your life have you been treated for Alcohol Abuse?
How many times have you had alcohol delirium tremens/withdrawal?
How many times in your life have you been treated for Drug Abuse?
How many of these were Alcohol detox only?
How many of these were Drug detox only?

How much money did you spend in the past 30 days on:

	$ Amount
Alcohol
Drugs

How many days have you been treated in an outpatient setting for alcohol or drug problems in the past 30 days? (Include NA, AA)
How troubled or bothered have you been in the past 30 days by alcohol problems?

Not at allSlightlyModeratelyConsiderablyExtremely
How troubled or bothered have you been in the past 30 days by drug problems?

Not at allSlightlyModeratelyConsiderablyExtremely
How important for you now is treatment for alcohol problems?

Not at allSlightlyModeratelyConsiderablyExtremely
How important for you now is treatment for drug problems?

Not at allSlightlyModeratelyConsiderablyExtremely
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
1. Did you feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Yes
2. Did you lose a parent through divorce, abandonment, death, or other reason?

Yes
3. Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Yes
4. Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Yes
5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Yes
6. Did you live with anyone who went to jail or prison?

Yes
7. Did a parent or adult in your home ever swear at you, insult you, or put you down?

Yes
8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Yes
9. Did you feel that no one in your family loved you or thought you were special?

Yes
10. Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

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

Not MuchSomeA Lot
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?"
Number of days since last use of alcohol and/or other substances:
1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an emotional problem?

YesNo
Last visit:
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?

YesNo
3. Have you ever been advised to take medication for anxiety, depression, and/or hearing voices, or for any other emotional problem?

YesNo
Medications:
4. Have you ever been seen by a mobile crisis team or in an emergency room or been hospitalized for mental or emotional reasons?

YesNo
Last visit:
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?

YesNo
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?

YesNo
Rate your current (right now) level of depression (0-none, 100-you need hospitalization):
Have you had thoughts of killing yourself or wanting to die in the last 30 days?

YesNo
Have you ever attempted to kill yourself?

YesNo
List years of attempts:
Last attempt was on:
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?

YesNo
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?

YesNo
Fears include:
9. Have you ever given in to an aggressive or angry urge or impulse that harmed yourself or others or destroyed property?

YesNo
Were you under the influence?

YesNo
10. Have you ever experienced legal problems associated with your sexual interests, your sexual activities, or your choice of sexual partner?

YesNo
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?

YesNo
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?

YesNo
List all symptoms that apply:
13. Have your relatives/friends/coworkers ever considered any of your beliefs strange or unusual?

YesNo
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?

YesNo
Number of times in the last year:
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?

YesNo
List all symptoms that apply:
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?

YesNo
Thoughts include:
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?

YesNo
List all symptoms that apply:
18. Have you been told by teachers or others that you have difficulty learning or a learning disability?

YesNo
Comments:
Please verify that you are human*
Should be Empty:

STEP2 Application Form

GENERAL INFORMATION

FAMILY/SOCIAL INFORMATION

EDUCATION & EMPLOYMENT INFORMATION

MEDICAL INFORMATION

MENTAL & EMOTIONAL HEALTH INFORMATION

LEGAL INFORMATION

SUBSTANCE INFORMATION

ADDITIONAL SUBSTANCE INFORMATION

Finding Your ACE (Adverse Childhood Experience) Score

MENTAL HEALTH SCREENING - MHS