Northern California - Intake Screening Form (Men Only)
Please fill in the form below. Note that this form is for male applicants only.
Owner ID
DATE
*
-
Month
-
Day
Year
CLIENT INFORMATION:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
DOB - depricated, replaced by Date of Birth for Salesforce sync
Age
Gender
Please Select
Male
Female
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
DL / ID Card
Yes
No
Have you ever been incarcerated?
*
Yes
No
Where?
How long?
Charges?
SS Card
Yes
No
Parole
Yes
No
Probation
Yes
No
Pending Court Dates
-
Month
-
Day
Year
Date
Do you have any of the following registration requirements?
PC 290
PC 457.1
PC 186.30
If you have any other registration requirements, please list them below:
Do you have any outstanding warrants?
Yes
No
Can you lawfully be around children?
Yes
No
Do you have any outstanding restraining orders?
Yes
No
Names / County
Back
Next
FAMILY:
How many children do you have?
Do you have an open CPS/CFS case?
Yes
No
Children's Mother?
Name(s) of Children
Gender(s)
DOB(s)
Do you have court ordered classes?
Yes
No
When are your classes?
Do you have visits with your children?
Yes
No
When are your visits?
SOBRIETY:
Last time you used drugs/alcohol?
-
Month
-
Day
Year
Date
Drug of choice?
Are you in a recovery program?
Yes
No
HOUSING STATUS:
What is your present living situation?
What city are you calling from?
Which cities have you lived in?
How many times have you been homeless in the last 3 years?
Have you been in a shelter?
Yes
No
Name of shelter(s)
Victim/Perpetrator of domestic violence?
Yes
No
Back
Next
HOMELESS PREVENTION:
Are you at risk of losing your home?
Yes
No
Are you at risk of your utilities being shut off?
Yes
No
Do you have a 3 day notice?
Yes
No
Do you have a shut off notice?
Yes
No
INCOME:
Do you have income?
Yes
No
Proof of income?
Yes
No
Type of income
Last occupation?
Cash Aid?
Yes
No
Cash Aid Amount
Day you received Cash Aid?
Food Stamps?
Yes
No
Food Stamps Amount
Day you received Food Stamps?
Did you complete high school?
Yes
No
Grade completed
GED?
Yes
No
Back
Next
MEDICAL:
Do you have any medical issues?
Yes
No
What?
Have you been diagnosed with a mental illness?
Yes
No
Diagnosis
Are you currently taking medications?
Would you benefit from counseling?
Yes
No
If suggested would you seek counseling?
Yes
No
Can you provide proof of a TB test?
Yes
No
Do you have physical limitations?
Yes
No
GENERAL QUESTIONS:
Do you generally get along with people?
Yes
No
Do you have a car?
Yes
No
Is your car registered?
Yes
No
Is your car insured?
Yes
No
Do you have good housekeeping habits?
Yes
No
How do you intend on being financially responsible?
What are your goals?
Submit
Should be Empty: