Admission Form

Community, Counseling, and Correctional Services, Inc.

Pre-Release Application

Name: _____________________________________ Center: _______________________

AO#: _______________________________________ Date: _______________________

Unit: _______________________________________

Section I: (Filled out by applicant)

Pre-Release: Why do you want to be accepted at the Pre-Release Center?

____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

How would going to Pre-Release affect employment, family relations, finances, and your ability to participate in treatment
services? (Be specific, which of these apply to you.)

____________________________________________________________________________________________________________

Prior Community Placement: Please describe any previous attempts to complete a pre-release or other community placement.
List locations and dates:

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Have you had any thoughts of self-harm or attempts at suicide? If so, when:

______________________________________________________________________________________________________________

Please describe reasons for failures in prior supervision placements: (i.e. Technical violations, dirty UA’s, or new crime
in the community):

______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Release plan: Upon discharge, where do you plan to settle? (At time of release.)

_______________________________________________________________________________________________________________

Later:_________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

What are your goals upon release?___________________________________________________________________________

_____________________________________________________________________________________________________________

Employment: Do you have a job offer or prospects upon release? Yes___ No___Give details (i.e. name of employer, type of
work, phone number and address). Summarize your employment history.

___________________________________________________________________________________________________________

Education: Do you have a GED? Yes___ No___ Give details of education beyond GED level, including vocational training.____________________________________________________________________________________________________

____________________________________________________________________________________________________________

CHEMICAL DEPENDENCY QUESTIONS:

1. Have you ever been in detox for drug or alcohol use? Yes___ No___ If yes, list where and when: ______________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

2. Have you ever been assessed for a drug/alcohol problem? Yes___ No___ If yes, list by whom, where, and when: ________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

3. Have you been told that you need to go to treatment for drug and/or alcohol problems? Yes___ No___ If yes, list by whom
and when:

____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

4. List all treatment(s) for drug and/or alcohol: (If more space is needed, continue listing on back of this page.)

Name of Treatment Program	Type of Treatment: inpatient, outpatient, intensive outpatient	Date	Complete Yes/No
1.
2.
3.
4.
5.

5. Have you ever attended AA/NA? Yes___ No___

6. Have you ever had an AA/NA sponsor? Yes___ No___

7. How many DUIs have you been convicted of: _______________________________

8. List the drug and/or alcohol related charges you were convicted of:

Charge/Date	Charge/Date
1.	7.
2.	8.
3.	9.
4.	10.
5.	11.
6.	12.

9. Do you have health problems as a result of your alcohol/drug use? Yes___ No___ If yes, please describe problems and
any treatments (if applicable).

__________________________________________________________________________________________________________

___________________________________________________________________________________________________________

10. Complete the following Release of Information form by filling in all areas marked with an (X). Under ‘Name of Program to
Disclose Information’ list the most recent treatment provider or assessment provider.

AUTHORIZATION OF DISCLOSURE
GENERAL CONSENT FORM

I, X_____________________________________Date of Birth X__________Date X_________
(Offender/Patient Name)

authorize X __________________________________________________________________
(Name of Program to Disclose Information) to disclose to: Staff and Screening Committees of Alternatives, Inc. (Billings Prerelease),
Community Counseling & Correctional Services (Butte Prerelease), Great Falls Transition Center (Great Falls Prerelease) Missoula Correctional
Services, Inc. (Missoula Prerelease) and Helena Prerelease Center.

_______________________________________________________________________.
(Name and Title of Person(s) or Organizations to which disclosure is to be made)

The following identifying information from my records (specify extent or nature of information to be disclosed):

CD Evaluation/Assessment, Diagnosis, Bio-psychosocial, Assessment, Discharge Summary

____________________________________________________________________________________________
____________________________________________________________________________________________

the purpose or need for such disclosure is to facilitate application review for prerelease and assess placement in prerelease.___________________________________________________________________________________

This consent to disclose may be revoked by me at any time except to the extent that action has been taken in reliance thereon.

This consent (unless expressly revoked earlier) expires up 6 months after date listed below.

(Specify date, event or condition upon which it will expire.)

Signature of Offender/Patient X __________________________________ Date X __________

Signature of Witness X _________________________________________ Date X __________

NOTICE TO WHOMEVER DISCLOSURE IS MADE: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any us of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

HEALTH QUESTIONNAIRE
Childhood Illness: Measles__ Mumps__ Rubella__ Chickenpox__ Rheumatic Fever__ Polio__
Immunizations and Dates: __Tetanus______________Pneumonia________________ __Hepatitis_____________Chickenpox_________________ __Influenza_____________MMR_______________________
Are you now receiving treatment for any medical, mental health or dental problems? Yes___ No___
If yes: name and address of provider(s)

Do you have or have you ever had:
YES NO	YES NO
Anemia	Tumor/Cancer/Cyst
Asthma	Radiation Therapy
Arthritis	Weakness/Paralysis
Back Problems	Abnormal Heart Conditions:
Depression	Heart Surgery
Diabetes	Mitral Valve Prolapse
Epilepsy/Seizures	Heart Valve Replacement
Fainting/Dizzy Spells	Chest Pain
Glaucoma/Eye Problems	Heart Murmur
Hepatitis: A	Heart Attack
B	Coronary Insufficiency
C	Pacemaker
Headaches	Stroke
Hearing Difficulty	Angina
High Cholesterol	Abnormal Bleeding
Immune Deficiency/Lupus	Blood Pressure ___High ___Low ___Normal
Inflammatory Rheumatism	Hemophilia
Kidney Trouble	Are you taking blood thinners
Liver Disease	Other: (Please explain)
Replacement (Knee, Hip, or Joint)
Sinus Condition
Thyroid	Women Only YES NO
Venereal Disease	Are you pregnant
	Are you taking birth control
Are you currently taking any of the following:	Are you allergic or have you reacted to
YES NO	YES NO
Antibiotics or sulfa drugs	Local anesthetics
Anticoagulants (blood thinners)	Penicillin
Medicine for high blood pressure	Other Antibiotics
Cortisone (steroids)
Tranquilizers	Barbiturates, sedatives or sleeping pills
Aspirin	Aspirin
Insulin, tulbutamide (orinase) or similar drug	Food
Digitalis or drugs for heart trouble	Other
Nitroglycerin

2. Have you ever received treatment for a medical condition requiring
admission to a hospital, on-going care, or surgery? ___YES ___NO

If yes, explain date, location, diagnosis, treatment, etc.:

3. Have you ever taken medication for any behavioral, mental, or emotional problem?
__YES __NO If yes, please list name and dosage of all medications.

4. Is there any physical or emotional condition that you believe requires
accommodation? (lifting or activity restrictions, assistance in ambulation, etc.) ___YES ___NO

If yes, please explain.

Has reasonable accommodation been made in the past? ___YES ___NO

If yes, please explain.

Is there anything that would limit your ability to participate fully in any correctional
setting (prerelease, boot camp, ISP, MSP, etc.) ___YES ___NO

If yes, please explain.

5. Has your ability to function/work/interact with others been impaired due to mood
and/or mind altering drugs? ___YES ___NO

If yes, please explain.

Have you had legal difficulties due to mood and/or mind altering drugs? ___YES ___NO

If yes, please explain. Include alcohol (beer, wine, or liquor), any drugs, medications or inhalants.

a. Were you using or under the influence of any substance at the time of ___YES ___NO arrest or at the time this crime was committed? If yes, what were you using?

b. Have you or anyone in your family had a history of substance abuse or ___YES ___NO
been in treatment (out-patient or in-patient) for substance abuse?

If yes, please explain.

c. Do you know if your mother used alcohol during the time she was ___YES ___NO pregnant with you? If yes, please explain.

6. Have you ever engaged in high-risk behaviors such as IV drug use or ___YES ___NO
multiple sexual partners? If so, please explain.

7. Have you ever been on S.S.I., S.S.D. or Medicaid? If so, please explain. ___YES ___NO

8. Do you have any lifting, standing or other physical limitations? ___YES ___NO

You are to pay court ordered restitution in the amount of: $_________________________

DISCLAIMER:

I understand the above questions and have answered truthfully and to the best of my knowledge.

I hold harmless the Community, Counseling, and Correctional Services, Inc. for failure on my part to disclose information.

________________________________________ _____________________________
Offender Signature Date

___________________________________________
Witness

TREATMENT HISTORY:

Educational/Vocational/Employment Skills:

____________________________________________________________________________________________________________

Treatment Program	Court Order	Court Recd.	Treatment Needs	Rejected Failed	In Group	Completion Date
SOP TX
M.H. TX
Anger Management
ED. GED
CP&R
CD
OTHER

HEALTH STATUS CATEGORY: ____________________________________________________________________________

Parole Eligibility Date: ___________________________________ Discharge Date: ______________________

Prior Disposition: ______________________________________________________________________________________

_______________________________________________________________________________________________________

Detainers: (Yes/No)____________________________ Counties: _____________________________

For: ___________________________________________________________________________________________________

_______________________________________________________________________________________________________

________________________________________________________________________________________________________

Last Disciplinary or Misconduct Report:

_______________________________________________________________________________________________________

________________________________________________________________________________________________________

WAIVER

I HAVE BEEN INFORMED OF the Pre-Release Program and I understand that I am being considered for placement, have read, understand, and accept the terms and conditions listed below.

Offenders Initials:

_____ 1. I understand that the Pre-Release Centers are not legally bound to accept any referral for pre-release placement.

_____ 2. I authorize the release of all medical, psychological, chemical dependency and criminal history information to be forwarded to the Pre-Release Centers for appropriate screening and handling of my case.

_____ 3. I will abide by all terms of placement.

_____ 4. I will abide by all Pre-Release Center rules.

_____ 5. I am responsible for all medical and treatment costs.

_____ 6. Although a Pre-Release Center resident, I continue to be an Inmate, and recognize that any unauthorized absence from the Center constitutes a Felony Escape, which carries a year consecutive sentence.

_____ 7. If I am returned to prison for other than medical reasons, I may be issued a Class II.

_____ 8. If I am returned to prison I will be allowed to bring only the property that is allowed to new inmates.

_____ 9. I am responsible for all debts incurred to the Pre-Release Center while a resident.

_____ 10. I am responsible for all debts incurred to Community Treatment Providers while a resident.

Client Signature: _________________________________ Date: ____________________

Witness Signature: _______________________________ Date: ____________________

EVALUATION:

_________________________________________________________________________________________________________

___________________________________________________________________________________________________________

____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Unit Management Team Unit Manager __________________________

Other _________________________________

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