Fillable TEC Application 2019

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TEC Application 2019

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1
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Initial EACH page for accuracy____
Program Application
7400 S. Virginia St. * Reno, NV 89511
775-853-5441 (office) * 480-247-5562 (fax)
www.EmpowermentCenterNV.com
The Empowerment Center (TEC) provides a residential program that requires a mandatory 120-day client
commitment, with a 30 day blackout. During blackout you are required to remain on campus and may not
possess a cell phone or other personal electronics. The program combines a strong 12-step recovery
component with an Outpatient Treatment component. This program is for women only who are sincerely
dedicated to achieving and maintaining a clean and sober productive lifestyle.
Your entry into TEC program indicates that you agree to:
• Complete this 120 day program - Including Blackout, finding a job
• Actively participate in all treatment requirements - Groups, 1:1 counseling
• Actively work a 12-step recovery program - Outside meetings, finding a sponsor
TEC does not serve individuals who have been convicted of a sexual offense, a crime against minors, or seniors.
Every section of this application must be completely filled out. If an item does not pertain to you, please mark it
with N/A. Incomplete applications will not be considered. Please write/print legibly.
PERSONAL INFORMATION
Name
Date
Current Address
NDOC #
City, State, Zip
Date of Birth (month/day/year)
Age
Phone Number
Social Security Number
Bed Date Requested
Emergency Contact - Name
Phone Number
Do you have a state issued picture ID?
(Not a prison ID)
Yes
No
Do you have your Birth Certificate?
(Mandatory for admission)
Yes
No
Veteran? Yes No Status?
EMPLOYMENT/EDUCATION
Concerning your ability to become employed, please answer the following questions completely.
1
What is the last job you held? Position?
Location? Hours per week?
Supervisors Name & Contact Information:
Do you have a current resume? Yes No
What is your highest level of education?
If you have special training, a Degree, or Certificate? What field:
Have you ever been convicted of a financial crime? (See # 8) If yes, how many:
4
Do you have a DOCUMENTED disability that may prevent you from seeking
employment? This does not exclude you from acceptance. See # 36.
Yes No
□ Didn't finish HS □ HS / GED □ Some College □ BS/BA □ MS/MA +
Initial EACH page for accuracy____
What types of jobs have you held?
What duties have you performed? Please list(ie. answered phones, stocked shelves, operated machine)
Have you ever supervised others?
6
Do you currently have any special tools or equipment?
Yes No
How many people did you supervise?
7
Do you currently have interview clothing?
Yes No
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2
3
5
Yes
No
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CRIMINAL HISTORY
If you DO NOT have a criminal history, please write N/A in this section. If you do have a criminal history,
provide ALL past and current criminal charges. A criminal history does NOT exclude you from entry into TEC
program. Your accurate information will help us to understand your current situation and any additional
services you may need. Use additional sheets if necessary.
8
Crime Convicted of
(List current first)
Sentence
9
Currently incarcerated:
Case manager’s name & contact
information?
County
State
10
Currently under supervision of
a Specialty Court?
Court supervisor contact information:
Yes
No
11
PED:
EXP:
12
Have you ever been convicted of a violent offense, an offense against a minor or a senior or a sexual
offense (do you have a tier rating)? If yes, please explain in detail, use additional sheets if necessary.
13
If in prison, how many write-ups/disciplinary actions have you had in the past 2 years? What were
they for? What was the month/year of each infraction? Use additional sheets if necessary.
14
What was your role in the crime(s) for which you were convicted?
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CRIMINAL HISTORY Continued
15
Do you have any other criminal issues that have not yet been resolved that may come up during your
time at TEC? This does not exclude you from acceptance.
ALCOHOLISM/ADDICTION
NOTE: If you have had a drug/alcohol evaluation in the past 12-months, please submit a copy with your
application if available. If you do not have a copy, you will be required to sign a release of information.
16
Do you have a drug or alcohol problem?
Yes
No
17
Have you ever been to a drug/alcohol rehabilitation program?
How many attempts? How many completions?
Yes
No
18
Are you willing to participate in TECs treatment component?
Yes
No
19
Are you now or have you ever been an intravenous drug user?
Yes
No
20
Have you ever developed a tolerance to any drug? (Meaning have you ever
had to use/drink more to get the same effect you got when you first used?)
Yes
No
21
Have you ever been arrested while under the influence?
Yes
No
22
Have you ever lost a job due to your drug or alcohol use? (For example, being
high or drunk on the job, being hung over, no call-no show, etc.)
Yes
No
23
Are you familiar with any 12-step programs? If yes, which one(s)?
Yes
No
24
Do you now participate in a 12-step program of your choosing?
Name of sponsor?
Last meeting date?
Yes
No
25 Are you willing to travel to meetings and get a 12-Step Sponsor?
Yes
No
26
Have you ever tried to control your drinking or drug use unsuccessfully?
If yes, how (willpower, 12-step, CR, other?):
Yes
No
27
What is your first drug of choice?
Method of use:
(smoke, IV, etc.)
What age did you first use:
Date of last use:
28
What is your second drug of choice?
Method of use:
(smoke, IV, etc.)
What age did you first use:
Date of last use:
29
What is your third drug of choice?
Method of use:
(smoke, IV, etc.)
What age did you first use:
Date of last use:
30
What was your longest period of abstinence?
From: To:
To what do you attribute this period of abstinence?
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MEDICAL/PSYCHOLOGICAL
Your medical/psychological information is confidential. Your personal health information will not be released
without your signed consent in accordance with federal law. Your medical/psychological information is not
considered in determining your eligibility for TEC program. Your accurate information will help us to
understand your current situation and additional services you may need. Use additional sheets if necessary.
31
Have you ever been diagnosed with a mental illness?
Yes
No
What was your diagnosis:
Year diagnosed:
Current medications:
Past medications:
Are you currently receiving mental health care? If yes, please list your provider’s name and contact
information.
32
Have you ever been diagnosed with a medical condition?
Yes
No
What is your diagnosis:
Year diagnosed:
33
Are you currently under the care of a physician?
Yes
No
If yes, physician name and contact information:
Current medications:
Past medications:
If accepted into TEC program, You will be required to submit a recent TB test or obtain one through us.
Date of your last TB test:
Result:
34
Do you suffer from chronic pain:
Yes
No
If yes, does it impair you from your daily functions:
Yes
No
How do you manage your pain:
35
Are you currently pregnant?
Yes
No
If you are currently pregnant please be aware, the organization does not have the ability to provide housing
for your newborn child. You should apply only if you can finish a 4 month program before you're due.
36 Do you have a DOCUMENTED disability? If YES, please describe below. Yes No
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General
The following three questions provide important information to help us understand who you are, and why you
are seeking help from TEC. If necessary, use additional sheets of paper, be thorough and WRITE LEGIBLY.
37 Why are you considering a recovery program?
38 Do you have an opinion regarding 12-step programs of recovery? Please tell us as much as possible.
39 Other than TEC, do you have alternative programs that you are considering? If so, what are they?
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Signature Date
Witness Date
STOP:
Prior to submitting this application, please review the contract to ensure
you:
• Are committed to this program of recovery
• You are willing to enter a 12-step program outside of TEC
during your time with us
• You are willing to find a sponsor and work the twelve steps
• You are willing to make the effort to get yourself to outside
meetings once you have completed your first 30 days
• Will abide by the rules of behavior for TEC
Prior to submitting this application, please review each page for completion.
Incomplete applications will not be considered.
The following page is a contract for residency. You MUST sign and have your signature witnessed for this
document to be considered.
General Continued
If you are depending on family/friends to pay your initial intake fees or contact us concerning information
about your bed date, you MUST sign the following release of information allowing us to speak to them.
I,__________________________, grant permission for Empowerment Center staff to discuss my admission,
financial arrangements, and substance abuse history with _________________________________(first and last
name). This release is valid for the duration of my time at the Empowerment Center.
___________________________________________
Signature Date
I understand that if I am involved with any state or federal prison OR law enforcement agency OR any
local, state, or federal court that the Empowerment Center, if required, may freely share information
regarding my admission status, program compliance, program progress, and discharge information at any
time.
___________________________________________
Signature Date
I state the ALL above information and statements contained in this application are true to the best
of my knowledge.
Please Initial ______
Please return this application to:
Email - **Preferred**:
admission@empowermentcenternv.org
In Person or by Mail:
Admissions
7400 South Virginia St
Reno, NV 89511
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THE EMPOWERMENT CENTER (TEC) CONTRACT FOR RESIDENCY
1. Alcohol/narcotic consumption and
gambling are prohibited on or off site as a
resident of TEC. Noncompliance will result in
immediate discharge.
2. All weapons are strictly forbidden.
3. Residents of TEC agree to random
urinalysis and breathalyzer testing.
4. Staff has the right to search your
possessions if alcohol, narcotics, weapons,
contraband, trafficking or theft is
suspected.
5. Theft is not tolerated. Residents are
responsible for their own possessions. Living
quarters are to be locked when not
occupied. TEC is not liable or responsible for
missing items.
6. Violence, including all forms of
physical, mental, or emotional violence,
intimidation, injury, abuse, negligent
treatment, maltreatment, or exploitation,
including sexual abuse, or harassment is
strictly forbidden. This includes, but is not
limited to verbal or physical conduct that
creates an intimidating, hostile, offensive
environment, or sexual in nature directed
toward any resident, visitor, staff or
volunteer of TEC.
7. TEC is an all female facility. There are
no intimate or sexual relationships allowed
among residents, or on property in any
form.
8. Smoking is not allowed on property.
9. Residents are required to use the
sign in/out sheets when leaving the facility.
All fields must be completely filled out,
legible, include your full name and your
time of departure and anticipated return.
You must use your legal name, NO
NICKNAMES.
10. All residents are expected to know
what phase they are on and comply with
all requirements as documented in their
phase packets.
11. All residents are require to abide by
a 30-day blackout. You may not possess
personal electronics of any kind. You may
not leave campus w/o TEC staff.
12. All visitors must be approved by TEC
staff.
13. Each client is required to complete a
minimum of one phase book weekly as
provided in his or her Resident Handbook.
Additional recovery work assigned by the
Recovery Mentor and / or Counselor is
expected to be complete in the time
agreed.
14. In the instance of illness, staff MUST be
immediately notified. Residents must
disclose to medical personnel that they are
in recovery from an addictive disorder and
may not be prescribed narcotics. Residents
must provide staff with copies of all
prescriptions and comply with all
medication management policies and safe
keeping requirements.
15. Upon discharge, you must remove all
your personal belongings. If your property is
not removed within seven (7) days it will be
considered abandoned. If you are unable
to personally remove your property, you
may give written authorization for a person
of your choosing to retrieve your property.
VIOLATION OF THIS CONTRACT MAY
RESULT IN IMMEDIATE DISMISSAL FROM THE
PROGRAM.
TEC staff will communicate with criminal
justice personnel assigned to your case.
Communication will be of an informative
manner to provide the criminal justice
professional with insight into your
reintegration in society, the program of
recovery and The Empowerment Center.
By signing this document, you agree to the
terms and conditions of this contract.
Signature Date
Witness Date
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Completed 9 December 2020

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