Elkhorn Treatment Center
Applicant Information Sheet
(Please type or Print)
This Page is to be completed by the individual referring an application to the Elkhorn Treatment Center (ETC)
Applicant Name: / DOC ID#: / Date:
Has the Applicant been sentenced? / Yes No
If yes, please list the sentence:
If no, when is sentencing scheduled for?
Present location of the applicant? / MWP Passages ASC Jail
OR in the community (name of city):
What is the projected release destination of this applicant upon completion of ETC?
Billings PRC Butte PRC Great Falls PRC Missoula PRC
Other (Specify):
Name and Title of Referring Individual:
Office Phone: / Cell Phone: / E-Mail:
Please check off & include the following items that are available in the application packet:
Information, Judgments, Sentence Review Decisions;
Initial board of Pardons and Parole Report and Dispositions;
Probation and Parole Bureau Violation Reports;
Department of Corrections Basic Information Sheet
Department of Corrections Initial Classification Summary and Report;
Department of Corrections Summary of Offender’s Institutional Conduct
Applicant Information Sheet
Application for Admission
Authorization of Disclosure form(s)
Please mail or fax this sheet and the referral packet to:
Amy Tenney, Director
Elkhorn Treatment Center
805 Colleen Street
Helena, MT 59601
Phone (406) 447-3281 Fax (406) 495-0582
Elkhorn Treatment Center
ALLOWABLE POSSESSIONS
The type and number of personal possessions that you are allowed at the Elkhorn Treatment Center (ETC) will depend on the level of treatment you are in. As you progress through the treatment levels you will earn privileges for additional personal possessions. Upon arrival at ETC, you will receive a program participant handbook that will list the personal possession privileges that you will earn as you progress through the three levels of treatment.
The following items are the only items that you are allowed to bring with you to the ETC. The clothing that you are wearing upon admission will be limited to 1-shirt, 1-pair pants, 1-bra, 1-pair of underwear, 1-pair of socks, 1-pair of shoes, 1-coat, 1-winter knit hat, and 1-pair of gloves. The list of allowable items below includes the clothing that you are wearing upon admission.
Allowable Items at Admission / Quantity
Coat, knit winter hat, winter gloves / 1 each
Prescription Eye Glasses (if applicable) / 1 pair
Jeans/pants (low riders not allowed), shirts (will be stored until phase eligible) / 4 changes
Bra, underwear, socks / 7 each
Shoes (Shower shoes highly recommended) / 1 pair each
Boots (winter) / 1 pair
Ring (wedding ring/band or engagement only) / 1
Ponytail holder / 2
Comb & Hairbrush / 1 each
Dentures (if applicable) / 1 set
Toothbrush, solid deodorant only / 1 each
Legal Papers / Per Policy
Religious medal/medallion (no larger than 2”x2”) / 1
Religious book / 1
AA/NA Big Book, 12x12, Daily Reflections (or any AA/NA Conference approved literature) / 1 each
Pictures (must fit on a 30x24 inch bulletin board) / Per Policy
Makeup / Not allowed
Everyday outer clothing will be provided by ETC, pending your level of treatment. Per policy, items that value $100.00 or more, with the exception of your wedding ring/band or engagement ring, will not be allowed. ETC is not responsible for your wedding ring/band or engagement ring if you bring it into the facility.
ETC is a tobacco free facility
Elkhorn Treatment Center
805 Colleen Street
Helena, MT 59601
Phone: (406) 447-3281 or Fax (406) 495-0582
Application for Admission
(To be completed by the application)
Thank you for completing this application. Please take your time and complete all questions/areas to the best of your ability. You may have someone review your application for completeness. Incomplete, missing, unclear, false, or misleading information on the application will delay the screening process.
1. / I am aware that Elkhorn Treatment Center (ETC) is a nine (9) month intensive treatment program for drug abuse/dependency. Yes No
2. / I am aware that I will be required to complete a prerelease program after ETC and that prerelease is approximately six (6) months long. Yes No
3. / I am aware that my admission to the ETC requires the approval of a screening committee.
Yes No
4. / I am aware that if approved for admission at ETC, I will enter ETC as a Montana State inmate.
Yes No
5. / I understand that failure to complete ETC will result in placement at a higher level of custody.
Yes No
6. / I am aware that should I walk away for attempt to walk away from ETC, I will be charged with felony escape. Yes No
If your answers are “Yes” to questions 1-6 above and you choose to be screened at ETC, please continue and complete the rest of this application.
My Name is:
(Last) / (First) / (Middle)
DOC ID#: / Date of Birth: / Age:
Name of Probation Officer:
Phone Number: / () / Cell: / ()
Current Legal Charges:
Sentence:
Date of Sentence:
Application for Admission
Page 2
I would like to tell the Screening Committee a little about myself. I was born in
, and grew up in
(City/State / (City/State
with / . I have / brothers and / sisters.
I / want to get my GED,
have a GED,
have a high school diploma,
have a post high school education, or
have a college degree.
I have / children. Their ages are / .
My children are currently living with: / in
.
(City/State)
I feel the closest to the following people: husband, boyfriend, mother, father,
brother, sister, aunt, uncle, grandmother, grandfather, children friend,
other (please list) / .
I believe the following people will support me while I am in Elkhorn Treatment Center:
The reasons why I want to be accepted at ETC are:
What I hope to get out of treatment is:
My goal(s) after treatment are:
I have placed a check by each drug that I have ever used, even once:
Alcohol / Marijuana / Cocaine / Methamphetamine / Amphetamines
Heroin / Narcotics / Ecstasy / PCP / Benzodiazepine
Barbiturate / Methadone / Oxycontin / Other (please list)
Application for Admission
Page 3
I have placed a check by my drug(s) of choice:
Alcohol / Marijuana / Cocaine / Methamphetamine / Amphetamines
Heroin / Narcotics / Ecstasy / PCP / Benzodiazepine
Barbiturate / Methadone / Oxycontin / Other (please list)
I have placed a check by my method(s) of use:
Drink / Snort / Drop / Smoke / Shoot
I have placed a check by the item that describes my frequency of use:
1-4 times a month / 1-5 times a week / daily / more than once daily
I last used the following drugs and/or alcohol on the following dates:
I have been diagnosed chemically dependent: Yes No If “Yes”, by whom:
In the past I have talked to a counselor about my drug/alcohol use: Yes No
I have attended AA/NA or am currently attending AA/NA: Yes No
I have overdosed on drugs and/or alcohol: Yes No If “Yes”, when:
I have been in detox: Yes No If “Yes”, when:
I have placed a check by the drug/alcohol treatment or counseling I have received:
Out Patient / IOP / Inpatient / ACT Class / MIP Class
Private Counselor / Other / Never talked to a counselor
My drug/alcohol counselor(s)/providers were:
Application for Admission
Page 4
I sometimes wonder if I might have a problem with gambling: Yes No
I have talked to someone about my concerns that I may have a problem with gambling: Yes No
I have attended counseling for gambling: Yes No I attended GA: Yes No
My counselor for my gambling problem was/is:
I have been referred for mental health counseling: Yes No
I have received mental health counseling: Yes No
I have been concerned that I may suffer from an eating disorder: Yes No
I have been diagnosed with an eating disorder: Yes No I was diagnosed on or about the following
date: / .
(If “Yes”, please list your mental health care provider(s):
I have placed a check next to the medications that I have taken, even once:
Antidepressant Medication / Anti-Anxiety Medication / Antibiotic Medication
Anti-Inflammatory Medication / Narcotic Medication / Other
If “Other” please list:
I am currently taking medications: Yes No If “Yes”, please list all of the medications that
you are currently taking (including birth control):
I am currently being treated for a medical and/or mental health condition:: Yes No
If “Yes”, please explain:
The names of my doctor/mental health provider(s) are:
Application for Admission
Page 5
I have been eligible for or received Medicaid, Medicare, SSI or SSDI benefits: Yes No
If “Yes”, please explain:
I have been hospitalized: Yes No If “Yes”, please explain where, for what, and when:
Sometimes I have had thoughts of harming myself: Yes No
I have caused harm to myself:: Yes No If “Yes”, please describe how and when this was:
I have or have had the following: / Yes / No / I have or have had the following / Yes / No
Anemia / Tumor/Cancer/Cyst
Asthma / Radiation Therapy
Back Problems / Weakness/Paralysis
Depression / Abnormal Heart Conditions
Diabetes / Chest Pain
Epilepsy/Seizures / Kidney Trouble
Fainting/Dizzy Spells / Abnormal Bleeding
Glaucoma/Eye Problems / Inflammatory Rheumatism
Hepatitis A / Hemophilia
Hepatitis B / Sinus condition
Hepatitis C / Thyroid
Headaches / Replacement (knee, hip, joint)
Hearing Difficulty / Liver Disease
High Cholesterol / Chickenpox Immunization
Immune Deficiency/Lupus / MMR Immunization
Blood Pressure: Circle One
High Low Normal / Sexually Transmitted Disease: Please list:
Any Heart Condition: Please List: / Pneumonia Immunization
Tetanus Immunization / Hepatitis Immunization
Application for Admission
Page 6
I am allergic or have had reacted to the following: / Yes / No / I am currently taking the following medication: / Yes / No
*Local anesthetics / Antibiotic or sulfa drugs
*Penicillin / Anticoagulants (blood thinner)
*Other Antibiotics / Meds for high blood pressure
*Barbiturates, sedatives or sleeping pills / Cortisone (steroids)
*Aspirin / Tranquilizers
*Food / Aspirin
*Other: / Insulin, tulbutamide (orinase) or similar drugs
Nitroglycerine
Are you taking birth control?
Are you taking blood thinners?
Other:
I have had the following childhood illness:
Measles / Mumps / Rubella / Chickenpox / Polio / Rheumatic Fever
I am pregnant: Yes No If “Yes”, when is the baby due?
I think I might be pregnant: Yes No
I have had reasonable accommodations made for me in the past: Yes No If “Yes”, please
explain:
I have the following limitations: Lifting Standing Other (Please explain):
I currently have family members in Riverside Youth Correctional Facility or Aspen Youth Alternatives:
Yes No If “Yes”, please list:
I currently have a family member(s) incarcerated: Yes No If “Yes”, please list who and where
incarcerated:
Application for Admission
Page 7
Thank you for completing this application. Please use the space below to share other information with the Screening Committee that you feel is important for them to know about you. Please feel free to use the back of this page if you need further space to write. If there is no further information that you would like to share please sign and date this application on the bottom of the next page.
My signature below reflects that I have answered all of the questions on this application honestly and to the best of my ability.
Applicant Signature / Date
Attached please find releases of information for drug/alcohol counseling information, medical information, mental health information, and/or gambling counseling information. If you answered “Yes” to any question asking if you have had drug/alcohol counseling, mental health counseling, current medical care or condition, or gambling counseling, you must complete a release for each provider. Your probation/parole officer can assist you in completing the Authorization of Disclosure form(s).
Please give the completed and signed Authorization of Disclosure form and your application to the person referring you to the Elkhorn Treatment Center. He/she will include these in your application packet.
Thank you for applying for Elkhorn Treatment Center. The results of your screening will be sent to the person who referred you.
Boyd Andrew Community Services
Elkhorn Treatment Center
AUTHORIZATION OF DISCLOSURE
GENERAL CONSENT FORM
I, / Date of Birth / Date:
(Client/Patient Name)
authorize
(Name of Program to Disclose Information)
to disclose to / Elkhorn Treatment Center’s Screening Committee and Elkhorn Treatment Center Staff
(Name and Title of Person(s) or Organization(s) to which disclosure is to be made)
The following identifying information from my records (specify extent or nature of information to be disclosed):
Dates of Treatment, Course of Treatment, Treatment Summary, Diagnosis, and Recommendations
for Continued Care
The purpose or need for such disclosure is / to facilitate screening at the Elkhorn Treatment Center,
and if approved for admission, facilitate admission to Elkhorn Treatment Center.
This Consent to disclose may be revoked by me at any time except to the extent that action ahs been taken in reliance thereon.
This consent (unless expressly revoked earlier) expires upon / 90 days from the date of screening at
Elkhorn Treatment Center
(Specify date, event, or condition upon which it will expire.)
Signature of Client/Patient / Date:
Signature of Witness / Date:
Signature of Parent, Guardian or Legal Representative / Date:
Specify Relationship
* / This information has been disclosed to you from records of Boyd Andrew Community Services, whose confidentiality is protected by Federal Law. Federal regulation (42 CFR, Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
(Elkhorn Treatment Center Application – Original 2/2/07)