Language
English (US)
Client Pre-Assessment Form
Please complete form in its entirety to the best of your ability. You will be contacted by an Operation Lighthouse representative within 24 hours of submission.
How Did you Hear About Us?
*
AWARE, Inc.
Butler County Community College at LindenPointe
Capable Kids
Catholic Charities
Communities that Care
Community Arts Experience of PA
Family Center
Haven Professional Counseling
HopeCAT
Isaiah 49, Inc.
Kid’s Special Needs Network
Laurel Technical Institute
Mercer County Behavioral Health Commission, Inc.
Mobility Management
One Kingdom Ministries, Inc.
Operation Lighthouse Project
Penn State Shenango
Primary Health Foundation
Prince of Peace
Recovery to Restoration
Shenango Valley Urban League
Slippery Rock University
The Beacon
Transportation Collaborative
Valley Baptist Church
Vocational & Psychological Services, Inc.
Zion Education Center, Inc.
CYPEN Crisis Response Team Partners
Name
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Prefix
First Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Best Time to Call
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Email
example@example.com
Marital Status
*
Married
Divorced
Single/Never Married
Separated
Widowed
Common-Law/Cohabitating
Primary Language
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English
Spanish
French
German
Chinese
Russian
Race
*
Alaskan Native
American Indian
Asian/Pacific Islander
Black/African American
White/Caucasian
*Refuse to answer
Ethnic Origin
*
Cuban
Hispanic
Mexican
Not Hispanic
Puerto Rican
*Refuse to answer
Place of Birth
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Number of People in Household
List all Dependent Children Living within the Home
Dependent Child's Name
Date of Birth
Name of School/Daycare
List Any Disabilities/Chronic Illnesses
1.
2.
3.
4.
5.
List Any Adult/Non-Dependent People Living Within the Home
Adult/Non-Dependent Name
Relationship
Age
Aware of HIV Status?
1.
2.
3.
4.
Highest Grade Completed
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No Formal Schooling
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade No Diploma
High School Graduate
GED or equivalent
Some College, No Degree
Vocational/Tech Program
Associate Degree
Bachelor Degree
Master's Degree
Doctoral degree
*Refuse to answer
Employment Status
*
Full-Time
Part-Time
Disabled
Homemaker
Unemployed
Student (Part-Time / Full-Time)
Retired
*Refuse to answer
Are you a Veteran?
*
Yes, Honorably Discharged
Yes, Dishonorably Discharged
No
Housing
*
Apartment / Condo
House
Mobile Home
Group Home
Transitional
Homeless
*Refuse to answer
Current living arrangements
Are there any inadequacies or safety concerns within the home? (Check all that apply)
Feel Safe
Unaffordable
Overcrowded
Utilities shut off
Criminal Activity
Physical Violence
List Any Diagnosed Health Issues or Concerns
Diagnosis
Dated Diagnosed
Treatment if Applicable
1.
2.
3.
4.
5.
Do you have health insurance?
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Yes
No
Complete Insurance Information.
Name of Insurance Company
Name of Subscriber (if applicable)
Group ID/Member Number
1.
2.
Additional Services Needed (Check all that apply):
Legal Assistance
SNAP Application
Cash Assistance
Transportation
Clothing
Food
Childcare
Spiritual Support
Domestic Violence
Adult Education
Addiction Support Group
HIPPA Notice of Privacy Practices Statement
E-Signature
*
I certify that all the information I have given is true and accurate to the best of my knowledge and belief. I agree to provide financial and other verification that may be needed to receive services. I also acknowledge to having the right to refuse any services offered by the Operation Lighthouse Project or any of their designated health care and/or service provider.
Clear
The Operation Lighthouse Project is funded by the Mercer County Behavioral Health Commission, Inc.
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