Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email
Handicapped
Yes
No
Offender
Yes
No
Labor Force Status
Employed
Underemployed
Unemployed
Not in Labor Force
No Work Experience
Other
Years of Gainful Employment
Under 1
1 to 2
3 to 9
10 or More
Emergency Contact Name
Phone Number
Gender
*
Male
Female
Other
Head Of Household
Yes
No
Marital Status
*
Single
Married
Divorced
Other
Highest School Grade Completed
*
1st-4th
5th-8th
9th-12th
GED
Ethnic/Group Classification
*
Black
Asian
Native American
Hispanic
White
Other
Military Service
*
Vietnam
Other Vet
Non-Vet
Socio-Demographic Background
Where are you Living At the Time of this Assessment
Please Select
Family or Relatives
Friends or Group
Homeless
Hospital or Rehabilitation Facility
Jail, Prison or other Correctional Facility
Other
How Many Hours per day (on average) do you Spend in Leisure or Social activities with your family
How Many Children do you Have
How Many Have their Primary Residence with you
How Many Receive Financial Support from you
How Many are between the ages 1 to 6
How Many are between the ages 7 to 12
How Many are between the ages 13 to 17
How Many Children are being raised by Grandparents
How Many are in DHS Custody
How long Have you been Living at this Address.
Were you Living with a Spouse or Primary Partner
Yes
No
How long have you been Living together
Socio-Demographic Background
Where are you Living At the Time of this Assessment
Please Select
Family or Relatives
Friends or Group
Homeless
Hospital or Rehabilitation Facility
Jail, Prison or other Correctional Facility
Other
How Many Hours per day (on average) do you Spend in Leisure or Social activities with your family
How Many are between the ages 0 to 6
How Many are between the ages 7 to 12
How Many are between the ages 13 to 17
How Many Children are being raised by Grandparents
How Many are in DHS Custody
Were you Living with a Spouse or Primary Partner
Yes
No
How long have you been Living together
INTERPERSONAL
Barriers to Employment
Age Too Young
Age Too Old
Lack of Education, Training skills, Experience or Obsolete Skills
Drug Abuse
Transportation
Childcare
Correctional Institution
Care of Other Family Member
How happy were you with the relationship?
Please Select
Unhappy
Somewhat Unhappy
Not Sure
Very Happy
Somewhat Happy
In the past 6 Months, did your spouse/partner get drunk frequently ( e.g., 2 or more times a month)
Yes
No
Use Drugs Other than Alcohol?
Yes
No
Got drunk Together
Never
Occasionally
Sometimes
Often
Always
Really Enjoyed being together
Never
Occasionally
Sometimes
Often
Always
Drank Together
Never
Occasionally
Sometimes
Often
Always
Used Other (illegal) Drugs Together
Never
Occasionally
Sometimes
Often
Always
Had Serious Talks about each others Interest
Never
Occasionally
Sometimes
Often
Always
Helped each Other with Problems
Never
Occasionally
Sometimes
Often
Always
Got Blamed or Fussed at About things you have done
Never
Occasionally
Sometimes
Often
Always
Had Disagreements
Never
Occasionally
Sometimes
Often
Always
Had big Arguments or Fights
Never
Occasionally
Sometimes
Often
Always
Have you ever gone to AA ( Alcoholics Anonymous), or other self-help meetings for an alcohol problem?
*
Yes
No
Have you ever gone to self-help meetings for drug addiction?
*
Yes
No
Have you ever used or still use the following drugs? Check all that apply
Never
Rarely
Sometimes
Ofter
Always
Cocaine
Crack/Freebase
Herion
Methamphetamine
Barbiturate
Marijuana
Other Sedatives
Have you graduated from high school?
*
Yes
No
Completed a vocational or technical training program?
*
Yes
No
When you were in elementary school (between age 6 to 10), were you given medication (such as Ritalin) to help you sit still?
Yes
No
In any special classes
*
Yes
No
What were all the different sources of financial support you had during the last 6 months
Your job or employment
Your spousor ex-spouse ( include child support)
Your Family
Unemployment Compensation
Welfare or public assistance (AFDC, Food stamps, etc)
Which of these was your main source of support in those 6 months
Do you have a current valid drivers license?
*
Yes
No
Do you have reliable Transportation?
Yes
No
What is your current legal status?
On Probation only
On Parole only
On Probation and Parole
Case Pending
Awaiting charge, trail or sentencing
Outstanding Warrant
None
Other
How often in the last 6 months have you experienced
Never
Rarely
Sometimes
Often
Always
Serious Depression?
Serious Anxiety?
Trouble understanding or concentrating?
Trouble controlling violent behavior?
Serious thoughts of suicide?
INTAKE FORM
Submit
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