UP-SKILL YOUTH ACADEMY
We kindly ask your cooperation in answering the following questions below as accurate as possible since they will assist the program manager in assessing your needs pre-appointment. All information given will be kept confidential.
Student Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select
Male
Female
Age
Birth Date
-
Month
-
Day
Year
Date
Education
Please Select
Middle School
High School Diploma
Some College
College
None
What is the highest level of education in your household?
Please Select
Middle School
High School Diploma
Some College
College
None
Do you have children?
Please Select
Yes
No
Do you have a valid driver license?
Please Select
Yes
No
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Next
Relationship
What is you relationship status?
Married
Never Married
Separated
Domestic Partnership
Widowed
Other
How would you rate your relationship well-being?
Not Functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not Functioning, 10 is No Problems
Employment
What is your employment status?
Employed
Unemployed
Retired
Self-employed
Disabled
Student
Homemaker
Other
How well are you doing your job?
Not working
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not working, 10 is No Problems
Is there anything stressful about your current work?
Family & Household
Including yourself, how many people live in your household?
Emergency Contact Name and Number
Please indicate if there is a family history of any of the following conditions;
Yes
No
Indicate Family Member
Anxiety
Depression
Substance Abuse / Alcohol
Arrested
Obesity
Schizophrenia
Suicide Attempt
Domestic Violence
Additional Comments
How would you rate your families support of you in this program?
Not functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not functioning, 10 is No Problems
History
Have you previously received any type of mental health services?
Yes
No
Please list your previous therapist(s)
Are you currently on psychiatric medication?
Yes
No
General Health Information
How would you rate your physical health condition?
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How often do you exercise?
None
1
2
3
4
5
6
7
8
9
Very Often
10
1 is None, 10 is Very Often
How would you rate your eating habits?(from healthy to not so healthy)
Very Unhealthy
1
2
3
4
5
6
7
8
9
Very Healthy
10
1 is Very Unhealthy, 10 is Very Healthy
How would you describe your stress level throughout the day?
Very Relaxed
1
2
3
4
5
6
7
8
9
Very Stressed
10
1 is Very Relaxed, 10 is Very Stressed
How would you rate your general happiness and well-being?
1
2
3
4
5
Symptoms
Please answer all of the statements below that describe your concerns
I often experience;
fear of many things
guilt
panic attacks
avoiding people
having nightmares
anxiety, nervousness
discomfort in social situations
Other
I often have;
suicidal thoughts
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts
violent thoughts
stress and tension
medical concerns
fatigue
work problems
Other
I often feel;
lonely
empty
sad
hopeless about the future
excessive guilt
suspicious
Other
Have you ever been been arrested?
Yes
No
If Yes check here if you have served more than 30 days total
Have you ever been been convicted of a sexual crime?
Yes
No
If Yes check here if you have served more than 30 days total
Have been referred as a matter of diversion?
No
Yes by the presiding Judge
Yes by the State Attorney's Office
Yes by the Public Defender's Office
Other
Do you have a plan for once you've completed the program?
What are your expectations from this program?
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Next
Are you committed to your own success?
CERTIFICATION
I hereby certify that I am age 18 or over and that I have the mental qualification to enroll myself into this program.
Name
First Name
Last Name
Signature
CERTIFICATION
I hereby certify that as the client is under age 18 that I am the legal parent or guardian and hereby have the authority by law or court order to enroll client into this program.
Signature
Name
First Name
Last Name
Continue
Continue
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