Operation Lighthouse Client Pre-Assessment Form

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? *
CYPEN Crisis Response Team Partners
Name *

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

: Hour Minutes AM/PM Option
Email
example@example.com
Marital Status *
Primary Language *
Race *
Ethnic Origin *
Place of Birth *

Street Address

Street Address Line 2

City State
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

List Any Adult/Non-Dependent People Living Within the Home

Adult/Non-Dependent Name

Relationship

Age

Aware of HIV Status?

Highest Grade Completed *
Employment Status *
Are you a Veteran? *
Housing *
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

Complete Insurance Information.

Name of Insurance Company

Name of Subscriber (if applicable)

Group ID/Member Number

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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