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Dear
Sir or madam, Thank you for your interest in our One Step
Closer programs. To better serve your needs and goals, we
have included a questionnaire that will provide us the answers
we need to ensure your success.
Date
___________________
Name.
_______________________
ADC
#________________________ Other_________
Date
of Birth __________________
Social
Security_________________
Drivers
License #__________________ State______ Expiration________
Arizona State Prison/Other Location ________________________________________
Male___________
Female________
Please
fill out the form completely, as this information will allow
us to determine which of our many faceted programs meet your
needs.
1.
Do you need a drug and alcohol program? Yes. ____ No.____
2.
Do you need an approved address to which you can parole? Yes.
____ No.____
3.
If require only housing, will you have the $450 move in fee
upon release? Yes. ___ No.___
4.
What are your available funds to cover move in costs? _______________________
5.
How much money will you have upon release? _____________________________
6.
Do you have access to any additional funds? Yes. _____ No.
_____
a)
If so, how much and from what source? _________________________________
7. What is your employment status?
a) I have a job waiting. ______ b) I need a job._______
Please
circle your job skills or trades.
Cashiers,
Administrative/Clerical, Retail, General, Social Services,
Trades/Labor, Automotive/Drivers
Healthcare/Medical, Hospitality/Travel, Restaurant/Food Services
Warehouse/Maintenance, or
Other______________________________________________________________
8.
What training, programs, or schooling did you receive during
your incarceration?
______________________________________________________________________
9 .Do you have a high school diploma? Yes. ____ No. ____
10.
If not, what is the grade level completed? _______
11.
Do you have any degrees? Yes ____ No. ____
12.
If yes, what fields are they in____________________________________________
13. What is the nature and degree of your crime _______________________________?
14.
What was your initial classification score? __________
15.
What is your current classification score? __________
16.
What will be your classification score upon release? __________
17.
Are you disciplinary action free? Yes. ____ No.____
18.
If not, please explain___________________________________________________
_____________________________________________________________________
19.
Are you a sex offender? Yes. ____ No. ____
a)
Are you required to be registered? _______________________
b)
Are you required to notify surrounding neighbors? ____________________
20.
Who is your CO 3? ____________________ Ph.# __________________
21.
Who is your probation/parole officer? __________________ Ph.#
_______________
22.
What is your release date? ____________________
Are
there any special terms to your release? ______________________________________________________________________
23.
Do you have any health issues, concerns or limitations Yes____
No ____?
If
Yes Explain___________________________________________________________
24.
Do you have any mental health issues or diagnosis? Yes_____
No____
If
Yes Explain___________________________________________________________
25.
What medications do you take, if any? ____________________________________
26.
What is your family status? Single. ______ Married. ______
27.
Do you have any children? Yes. ____ No. ____
a)
If so, how many? _________
28.
Will you be living with your family upon release Yes. ___
No. ____
29.
Do you need help with family issues? Yes ____ No. ___
30.
What will be your source of transportation to our facility?
a)
Name of this a friend or family member_________________________________
b)
Please give phone number. H.__________W. _____________C. ____________
c)
I need help with transportation to One Step Closer. ________
d)
How did you hear about us____________________________?
31.
What are your short-term goals? _________________________________
32.
What are your long-term goals? __________________________________
33.
What help do you need to achieve them? _________________________
34.
Space is provided below if you wish to elaborate on any issue.
Thank you for your cooperation. We look forward to meeting
you.
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