Case Planning Form

Case Planning

Risks, Needs, and Goal Setting
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.
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?

yes for multiple crimesyes for the same crimeno
What do you feel has prevented ongoing success? Click all that apply

Little help with financesLittle help with social supportLittle help with health (physical or mental)Little help with trauma or addictionI haven't wanted or been ready to changeOther
Do the people you associate with support your choices?

Yes, they also engage in criminal activity.Yes, but they don't engage in criminal activity.No they don'tother
Have you ever victimized someone?

Physical Assault malePhysical Assault FemaleSexual AssaultRobbery or TheftProperty DamageOther
Have you ever been victimized? (share below if you want)

YesNo
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)

Bipolar DisorderAntisocial Personality Disorder ASPDBorderling Personality Disorder BPDPTSD / TraumaSchizophreniaADHD
Have you ever struggled to cut back or quit drugs or alcohol?

YesNoI didn't want to but it was problematicI don't believe it was a problem
When you look back at childhood, how does it make you feel? (check all that apply)

It was happyThere were issues but I have managedI have traumaI may have trauma
Do you have a family?

Long term partnerLong term partner and childrenChildrenShort term partnerShort term partner and children from this or another relationship
When you look at your interpersonal relationships (romantic partner, children, family) how do you respond to stress?

I can problem-solve with others without issuesI run away when there's conflictI use aggression or violence towards my partner, children, familyThere's a mix of the above
Do you have the skills to gain and maintain employment?

YesNoUnsureNot enough to maintain myself and family
Do you have hobbies and activities where you have fun without using drugs, alcohol, or criminal acticity?

YesNoNo, but I'm tryingI'm not sure how to
Do you have feelings of low self-worth, shame and guilt, or low self-esteem?

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

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

YesNoDepends who I'm withDepends on the situation
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

CommunicationConflict Resolution (solving problems)AngerDepressionAddictionTraumaNegative Beliefs about SelfOther
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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