Case Planning Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

This form is to assist you and The Bridge staff in understanding your risks, needs, goals, and steps to achive them.

Be as honest as possible, we all make mistakes. By reflecting, we can see where we went wrong and what we want now. There is no judgement here. At the end of the form, please provide a "best case" view of what you want in life. We will assist you in finding ways to achieve that realisticlly and when we need to, with your permission, find others and other agencies who may be able to help.

Thank you

Have you been arrested more than once?

What do you feel has prevented ongoing success? Click all that apply

Other

Do the people you associate with support your choices?

Have you ever victimized someone?

Have you ever been victimized? (share below if you want)

If you wish to share about your own experience as a victim, please share here:

Do you feel like you may have or have you been diagnosed with any of the following?(check all that apply)

Have you ever struggled to cut back or quit drugs or alcohol?

When you look back at childhood, how does it make you feel? (check all that apply)

Do you have a family?

When you look at your interpersonal relationships (romantic partner, children, family) how do you respond to stress?

Do you have the skills to gain and maintain employment?

Do you have hobbies and activities where you have fun without using drugs, alcohol, or criminal acticity?

Do you have feelings of low self-worth, shame and guilt, or low self-esteem?

Do you feel distressed often (anxious, worried, unsure about your future)?

Do you struggle with impulse (acting before thinking, blurting out things you later regret, getting angry quick then feeling bad later, etc)?

If you could change your childhood, what would you change?

If you could change your past, what would you change?

What are your strengths? Example I am smart, I'm resilient, I like to help others

What are your needs? Example I can't maintain a job, I keep re-offending, I get mad easily, I have no stable housing

What would your life look like if you woke up tomorrow and life was great?

What type or area of skills would you benefit from learning about? Click all that apply

Please provide any information about yourself, your life, and your history that you feel would assist in working with you in obtaining your goals and minimizing your risks:

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