Crisalida and CAA intake

Community Anchor Academy

intake form
Community Anchor Academy 1652 S. Circle Dr. Colorado Springs, Co. 80910

WHealthy Unlimited 121 E. Bijou Colorado Springs, Co. 80903

Crisalida 4180 Center Park Drive, Colorado Springs, CO 80916-4505 719-698-8036 www.crisalida.org
Date*

MonthDayYear
Date
Name of Client*
Your name
Email(your email) if you want to potentially win a prize
example@example.com
Age*
Date of Birth*

MonthDayYear
Date
Sex*
Marital status *
Occupation(type of job)*
Ethnicity*
Were you born in America*
cell/personal Phone Number
Work phone number
Home phone number*
Leave a message*

Yes
address( numbers, street name, apt/unit number or name only)*
County(current)*
City*
Hu
State*
Zip code*
Email(if you Don't have one, get one)
example@example.com
Highest level of education *
Do you have a IEP(individual education plan) or a 504 plan*

Yes, I have a IEPNo, I do not have IEPI dont know If I have IEP
Certificates completed(current/updated)*
(Choose all that apply that are current and updated)
Trade schools*
Parent or Guardian Name (if the client is a minor):
Parents Name

First NameLast Name
Relation
Celll Phone
Household Members (how many people live in your house with you)
Work Phone
Name(household member)
Age
Name(household member)
Age
Who will pay for this service*

Clients/parentsWraparound(another organization non-profit)ShelterSchoolOtherMedicaidMedicareTricare
if other, specify
Contact Name If not the client
Phone # of Contact
Emergency Contact
Emergency contact Phone Number
Relation to Client
Immediate Needs-Maslow*

Housing( I need a place to stay)Food( I don't have access to food)I need a phone(I don't have a phone)I need a transportation(I dont have reliable transportation)I don't have clothingI feel unsafeI need a job
All of the information discussed during the session is confidential and cannot be discussed with anyone without your permission in writing except when required or permitted by law. Mandatory Disclosure can be required under these certain circumstances: if there is suspected child, dependent, or elder abuse; when there is reasonable belief that the client means to endanger themselves or others, unless there is a means of protection. Client information can also be disclosed if required legally. All identification information of the client is strictly confidential.
Client Signature*

Clear
Date*

MonthDayYear
Date
I/We, the parent or guardian of the client, give consent to the provision of counseling services at Crisalida, Inc. This authorization is effective unless canceled by the signer.
Parent Signature

Clear
Date

MonthDayYear
Date
Community Anchor Academy

1652 S. circle dr. and Whealthy Unlimited 121 E. Bijou colorado springs Co.
Crisalida, Inc.
(check all that apply to you)*

TensionImpulsive ActionsHomicidal Thoughts(wanting to harm others)No eatingBinge eatingDifficulty ConcentratingSexual tendenciesHallucinatins(hearing voices in head)Crying EpisodesLoss of faithConstantly worriedExcessive energy (unable to stand still)Problems SleepingBad thoughts or dreamsPurgingLoss energyForgetfullnessUncontrollable agreeLoss of motivationAccelerated heart rateObsessive ThoughtsHyperactiveFlashbacksSubstance AbuseIrritabilityOtherN/AIntrusive thoughtsYou need help navigating hard times
adjusting to changes/challenges and pivoting*

I stress when faced with a changeI have trouble when coping with changeNavigating hard times are toughI don’t like facing new challengesI have trouble adapting to changeImperviousChange can be overwhelming
Have experience the following types of abuse(mark all that apply)*

EmotionalSexualMentalWitnessed abuse by anotherPhysicalHas abused othersN/AI have stressful life changes
I communicate well with others*

OftenSometimesRarely
I handle myself with Authority(you carry yourself with confidence, self assurance)*

OftenSometimesRarely
I handle myself well with my friends(confident in social situations)*

OftenSometimesRarely
I am capable of creating goals and working towards them*

OftenSometimesRarely
I have the support of my family and/or friends*

OftenSometimesRarely
I am satisfied with my relationships*

OftenSometimesRarely
I know how to set boundaries in my intimate relationships*

OftenSometimesRarely
I like who I am(even when I am rejected by others)*

OftenSometimesRarely
I am able to laugh at myself*

OftenSometimesRarely
I respect myself*

OftenSometimesRarely
I am happy with who I am*

OftenSometimesRarely
In my relationships(answer the following questions as in regards to current and previous relationships)
We argue and fight over everything*

OftenSometimesRarely
When we are together I feel as if we are walking on egg shells*

OftenSometimesRarely
I feel responsible for our problems*

OftenSometimesRarely
Alcohol and drugs affect our relationship*

OftenSometimesRarely
I feel isolated and depressed*

OftenSometimesRarely
I feel Controlled by my spouse*

OftenSometimesRarely
I have experience With..........
Damage in personal relationships/or have issues in school or work due to my anger*

YesNo
Legal issues (for example, traffic tickets, jail time, parole etc.)*

YesNo
What I have or who I am.........
I have legal, financial, mental health, work, school, familiar, friendship, or relationship problems caused by the use of alcohol or illegal substances*

YesNo
Using drugs to cope with alcohol*

YesNo
I have been called a alcoholic or addict*

YesNo
I am receiving treatment for for substance abuse*

YesNo
Members of my family have struggled with substance abuse*

YesNo
Have you received mental health treatment before*

YesNo
When?
when did you receive these services the last time
For How Long?
What was the objective for the treatment? ex. copping, addiction, reframing negative thoughts, self-esteem, dealing with depression, trauma, PTSD
Please provide the name number and address for your previous therapist/clinician
Have you undergone Psychological test*

YesNo
For How Long
If yes, when?
Please provide the name number and address for your previous Psychiatrist/psychologist
Have you ever been been hospitalized for mental health problems?*

YesNo
When
if yes, For How Long
Why were you hospitalized
Please provide the name number and address of the treatment therapist
Are you taking any medications?*

YesNo
For How Long
Who prescribed it
When
have you taking any medications for mental or emotional conditions?*

YesNo
For How Long
Have you ever attempted suicide*

YesNo
If yes, when?
Describe the circumstances that made you consider it
are you currently contemplating(thinking about) suicide*

YesNo
If yes, do you have a plan

YesNo
Please describe your childhood*
describe your childhood*
Why are you seeking counseling or treatment Please describe*
Do you have goals for your treatment

YesNo
what are your additional goals if not listed
Do you have concerns for your treatment

YesNo
If yes please explain

Family History*

	Name	age	Alive or deceased	Describe Relationship(two words max)
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5

Are you religious or spiritual*

YesNo
If yes, what religion/spirtuality*
Do you call on your religion in hard times*
Hobby #1*
Hobby #2*
Hobby #3*
Please describe more of your interests or hobbies
Are you involved in the legal system*

YesNo
Legal status*
Conviction status*
Conviction status(choose all that apply)*

First time felonMultiple FelonsMisdemeanor convictionsDUI convictionsDomestic violenceSexual offenseViolent offenderNo convictionsDishonorable discharge
If yes describe
Medical History
Primary Care Doctors Information( put N/A if you Don't Know)*
Date of last exam

MonthDayYear
Date
Medication Without prescription from doctor/clinician(choose all that apply) you use currently or in the past*

AlcoholPrescription MedicationCrystal MethEcstasyCocaineMagic MushroomsAcid(LSD)SteroidsMarijuanaInhalants(paint/Gasoline/Cleaning produs/compressed air)Stimulant(heroin, methadone, OxyContin, Vicodin, etc.)CaffeinePhencyclidine(PCP, love boat, Wet, angel dust)Nicotine(cigarillos/cigarettes)Vape pen(nicotine)Vape Pen(marijuana)FentanylKetamine(special K)OtherNone
Condition(check all that apply)*

High/low blood pressureDiabetesPhysical injurynone
Treatment status*

blood pressure- yes-current and treatedDiabetes-yes-current and treatedPhysical injury-yes-current and treatedBlood pressure-past-untreatedDiabetes-past and untreatedphysical injury past and untreatedN/A
Blood pressure details or additional information
Diabetes details or additional information
Diabetes details or additional information
Client Signature*

Clear
Advance Childhood Experience (ACE)
Adverse Childhood Experience (ACE) Questionnaire
1. Did a parent or adult in the household often swear at you, put down, or humiliate you and/or act in a way that made you feel they were going to physical hurt you?*

YesNo
1 ACE Calculation
2. Did a parent or adult in the household often push grab, slap or throw something at you and/or ever hit you so hard you had marks or were injured*

YesNo
2 ACE Calculation
3. Did a parent or adult or person at least 5 years older than you ever touch or fondle you or have you thier body in a sexual way and/or attempt or actually have oral, anal, or vaginal intercourse with you?*

YesNo
3 ACE Calculation
4. Did you often feel that: no one in your family loved you or thought you were important or special and/or your family didn't look out for each other, feel close to each other, or support each other?*

YesNo
4 ACE Calculation
5. Did you often feel that: you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? and/or your parents were to drunk or high to take care of you or take care of you to the doctor if you needed?*

YesNo
5 ACE Calculation
6. were you parents ever separated or divorced?*

YesNo
6 ACE Calculation
7. were any of your parents or other adult caregivers Often pushed, grabbed, slapped, or had something thrown at them or sometimes or often kicked, bitten, hit with something hard, or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?*

YesNo
7 ACE Calculation
8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?*

YesNoType option 3
8 ACE Calculation
9. was a household member depressed or mentally ill or did a household member attempt suicide?*

YesNo
9 ACE Calculation
10. Did a household member go to prison?*

YesNo
10 ACE Calculation
ACE total
PHQ 5 and GAD 7

PHQ 5*

	Not at all	Several days	More then half days	Nearly every day?
1. Little interest or pleasure in doing things
2. Felling down depressed or hopeless
3. Trouble falling or staying asleep or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or over eating
6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching
8. Moving or speaking so slowly that other people could have noticed to the opposite- being so fidgety or restless that you have been moving around a lot more than usual
9. thoughts that you would be better off dead, or hurting yourself in some way

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficultN/A

PHQ 5

	Not at all	Several days	More then half days	Nearly every day?
1. Little pleasure in doing things
2. Feeling down depressed or hopeless
3. Trouble falling or staying asleep
4. Feeling tired or having little energy
5.poor appetite or over eating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things such as reading the newspaper, or watching television
8. Moving or speaking so slowly that other people could have noticed or the opposite - being som fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting in some way

PHQ-Calculation

GAD-7*

	Not at all	Several days	More then half days	Nearly every day?
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that its hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

GAD-Calculation
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? (Choose one)*

Not difficult at allSomewhat difficultVery difficultExtremely DifficultN/A
Appearance: How would you describe your Appearance(currently)*

Kempt/neatUnkempt/messy/scruffyWell groomedTattoosAppears stated ageappears older than stated ageAppears younger than stated age
Eye contact: how would you describe your Eye contact right*

GoodFairPoor
Attentiveness: describe your focus/awareness/attentiveness*

AttentiveResistantDistractedPreoccupied
Mannerism/behavior/trait*

are you CooperativePleasantare you AngryGuardedSeductive
Alertness/awareness now*

DrowsyStuporAlert
Motor: Can you describe how you're feeling physically? Do you feel unusually active or stuck at times?*

NormalAbnormal(tics, tremors, grimaces, grinding teeth)Mental handicapAgitated
Speech:Describe your speech/cadence and style currently*

Loudunremarkable/normalSlowedquietfast/rapidslurred
Affect: How would you describe your emotions right now?(observable emotions)*

erratic/up and downDramaticunemotional/detachedall feelings are present and appropriateStable/consistent/appropriateConstricted/reserved/holding back
Mood: "How are you feeling right now?"Mood*

NeutralCalmDepressedIrritable/irritatedAngryuninterested/uncaringoverly happy/ecstaticNervous/anxious/fidgetySadFearful
Thought Content: Can you describe your thoughts about yourself and how others often see you?*

Normalobsession/obsessiveOver confident/ unrealisticMiss understand eventsDelusional disorder/paranoid disorderModest/humble/self-criticalParanoiaoverthinking/DwellingWorthless hopelesssuperstitious /illogicalThreateningPhobias/apprehensive/averseDelusional
Thought content: suicide Ideation*

noin the past I had ideationsActive(currently have suicide ideations)I Plan on committing suicideI have a desire to commit suicideI have the equipment/tools to commit suicide
Thought Content: Homicidal Ideation*

Denied? I don't have any thoughts of homicideIn the past I had ideationsActive(currently have homicidal ideations)I Plan on committing homicideI have a desire to commit HomicideI have the equipment/tools to commit Homicide
Thought processes: Which of the following best describes how your thoughts are organized when you talk or think about something?*

Connected and focusedTalking too much without a clear point (Rambling)Repeating the same ideas over and over (Perseverative)Going off-topic but still somewhat related (Tangential)Jumping quickly from idea to idea without finishing a thought (Flight of Ideas)Hard to follow, but still makes some sense (Circumstantial)Thoughts that don’t make sense or don’t connect at all (Illogical, Incoherent)Words jumbled together in a way that doesn’t make sense (Word Salad)Going off-topic but still somewhat related (Associations)Jumping from one idea to another with weak or unclear connections (Loose)
Perceptions: Have you ever noticed something strange with your senses, like hearing, seeing, or feeling things that others don’t?(perceptions)*

Do you hear things that are not thereIn the past I had ideationsDo you feel disconnected from yourselfDo you smell things that people don'tdo you see things that nobody else can see, phantom imagesDo you feel things that others cannot feelDistorted perceptionsUnknown
Date*

MonthDayYear
Date
Participant Name(your name)*
Date of Birth(participants)

MonthDayYear
Date
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute, 1999.
Client Name*
Date Enrolled*

MonthDayYear
Date
Case Number
Session Date

MonthDayYear
Date
location of where you will receive services(choose one)*
Session Time
DateTime
Session End Time
CPT/HCPCS
Diagnosis
Risk Factors
Protective Factors
Additional Details
Identification age ethnicity religion marital status referral status etc
Age*
ethnicity*
Religion*
History of present problem(choose all that apply)*

Receiving support and services at Community anchor academy and Whealthy Unlimited)Receiving support and services at WHealthyI am now soberI am not SoberI have a drug convictionI have been battling addictionI Have a DUIMy family has a history of alcoholismMy family has a history drug addictionI have a history of drug addictionI have a history of alcohol addictionI am in currently or have been been in drug courtI have a DUI pending
History of present
Psychiatric history*

mom has a history of mental health issuesdad has a history of mental health issuesSiblings has a history of mental health issuesGrand parents has a history of mental health issuesFamily has a history of mental health issuesI have symptoms of mental health issuesI have been diagnosed with mental health issuesI have been placed in the state hospitalI have IEP or 504 learning planI currently see a therapist or professional for mental health issuesI use to see a professional for mental health issuesI have suffered a mental breakdownI take medication for mental health issuesI am prescribed medication for my for my mental health issues but I don't take itN/A
Psychiatric History prior episodes of symptoms diagnoses courses of treatment etc
family history*

mom has a history of mental health issuesdad has a history of mental health issuesSiblings has a history of mental health issuesGrand parents has a history of mental health issuesFamily has a history of mental health issuesAunt and uncle has mental health issuesCousins have mental health issuesN/A
Family Psychiatric History history of mental illness in family diagnoses etc
What's your Trauma history(choose all that apply)*

PTSDSexual abuse by person of trustParental mental illnessSexual abuse/assaultVictim of violenceNatural disasters victimBrain injury(concussion)N/ASubstance use disorderSerious Medical Illness or Injury – Personal or family history of life-threatening conditions.Child abuse/neglectIncarceration or Legal Issues – Personal or family history of imprisonment.BulliedRacial or Cultural Trauma – Discrimination, systemic oppression, or generational trauma.Military-Related Trauma – Combat exposure, PTSD from deployment, or family military separation.Sexual exploitationCommunity Violence – Exposure to shootings, gang violence, or unsafe living conditions
Trauma History nature of trauma when occurred persons involved etc
History Medical conditions(choose all that apply)*

Broken bonesHigh blood pressureDiabetesStrokesObesityback issuesShould issuesHepatitis B and or CSTDHIV/AIDSKidney DiseaseAsthmaCancerCancer in remissionConcussionChronic MigranesCan not lift heavy thingsN/AFood allergies
Medical Conditions History current and past medical conditions treatments allergies etc
Insurance provider
Upload a photo of insurance

Cancelof
Medications for mental health(choose all that apply to you past and present )*

Sertraline (Zoloft)Fluoxetine (Prozac)Bupropion (Wellbutrin)Escitalopram (Lexapro)Aripiprazole (Abilify)Quetiapine (Seroquel)Risperidone (Risperdal)Alprazolam (Xanax)LithiumMethylphenidate (Ritalin, Concerta)OtherN/A
Dosage(how much are you Prescribed to take per day)?
Example. Two pills per day
Medications for substance abuse (Check all that you use or used)*

Methadone –Buprenorphine (Suboxone, Subutex)Naltrexone (Vivitrol, Revia)Disulfiram (Antabuse)Acamprosate (Campral)Bupropion (Zyban, Wellbutrin)Varenicline (Chantix)ClonidineGabapentin (NeurontinTopiramate (Topamax)OtherN/A
Dosage number Substance abuse (what is the amount of the above medication you take per day)
Medication(for physical health conditions) (check all that apply)*

Blood pressure based medicationOxycodoneInsulin,MeforminIbuprofen/TylenolTramodolNeurontin)AlbuterolUses a inhalerAmoxicillin –Muscle relaxersN/AOthersFentanyl
Current Medications medication dosage purpose prescribing physician
Substance use disorder (drugs abused)*

CocaineMethamphetaminesWeed/MarijuanaPrescription drugsHeroinCocaine/CrackAlcoholFentanylHydrocodoneMorphineAdderallBenzodiazepines (Xanax, Valium, Ativan)LSDsilocybin (Magic Mushrooms)Nitrous Oxide (Laughing Gas)Solvents (e.g., glue, paint thinner)OtherN/A
What city/country do you call home? what is your families ethnicities/race? *
What's Family History family of origin relationship with parents siblings significant others etc
Who do you have a good strong relationship with(check all that apply)*

MotherFathergrandparentsSister(s)Brother(s)Step dadStep-momAunt(s)Uncle(s)religious leader(pastor)Foster parentMentorPeer coachLife/sports coachFriendsTeacher/professorNobodyWifeHusbandPartner(significant other)BoyfriendGirlfriend
Over all my family supports me*

YesNoI dont have a support system
Social history( social circle that helps you or you have a relationship with)(choose all that apply*

Community organizations/resoucesSupport groupstherapist/clinicianFriends circlereligious circle(Church,masjid/temple etc. )religious circleReligious/spiritual leaderI don't have a social circle that supportsBarber/stylist/nail techWorkout partner
Social History significant relationships social support naturequality of relationships current community resources etc
Spiritual/cultural/religious/practices (all the apply)*

IslamChristianityCatholicJudaismHinduismBhuddiasimnon-religiousSikhismTaoismSanteriaSatanismWitchcraftWiccanShintoConfucianismpersonal spiritualityAtheismNon-religious/non-spiritual
SpiritualCultural Factors important spiritual practices and communities cultural influences etc Developmental History developmental milestones delays etc
Employment(work history)(check all that apply*

I am, unemployedDisabled cannot workCollects SSIemployedlooking for workLooking for a better jobI have no interest in workingI don't want to work in fear of losing my benefitsRetiredveteran1-3 years of work historyEntrepreneur(has an active business)4-7 years of work history8-10 years of work history10(+) years of work history
Educational/vocational history*

graduated high schoolSome high schoolAssociatesBachelorsMastersSome collegesome trade schoolTrade school(journeymen)Trade school(apprentice)GEDCertifications(A+, IT, cyber security, Flagger etc.)OSHAPeer support/coach and family specialistBarber/stylistnail techin high school/GED program
Work history job types(choose last three jobs)*

AutomotiveAgriculturesalesCustomer serviceIT/computerHealthcareFinanceRetailCulinary/foodWarehouseEducationmanufacturingEnergyLegal servicesHuman servicesNon-profitGovernmentMilitaryReal estateadministrativeSolarEntertainmentInfluencer/content creatorEntrepreneur(business owner)None/N/AOther
Jobs/career you are looking for (choose three jobs)*

AutomotiveAgriculturesalesCustomer serviceIT/computerHealthcareFinanceRetailCulinary/foodWarehouseEducationmanufacturingEnergyLegal servicesHuman servicesNon-profitGovernmentMilitaryReal estateadministrativeSolarEntertainmentInfluencer/content creatorEntrepreneur(business owner)None/N/AOther
Legal History(convictions)(choose all that apply)*

Sex offenderDrug convictionDUIDomestic violenceSpeeding ticketsAssault/batteryMenacingTheftRobberyon probationOn paroleon Deferred sentenceTraffic ticketson federal probationopen case/pendingN/aHalfway house(from prison)Halfway house(direct sentence)on House arrestI have been convicted felony(s)I have been convicted misdemeanorsI have been to prisonI have been detained by ICEI have been to county jailI am on bail/bond
Legal History arrestsummons history sentencing DUI occurrences incarceration civil litigation family court matters etc
What are your strengths(choose top 3)*

leadershipCommunicationHonestySelf-disciplineresilienceCreativeKindHumorIntelligenceGratitude
What do you need(choose top 3)*

Job/careerSupport goupstransportationbaby sittermedicaladdiction counseling/supportanger mangementmental health supportMedicationtherapistsDoctorDentistwork attire/PPEtattoo removalFood/nutritionhaircut/stylistEducation
I prefer the following what are your preferences(select all that apply):*

prefer to be emailedto be calledto be textone-on-one sessionsGroup sessionslifting weightscardio trainingin person sessionsvirtual sessionsYogaremote workquiet workspaceworking in teamsnight shiftday shiftthird shifthard laboroffice workpeer coachclinican
What are your Abilities(all that apply)(choose top 3)*

MathLiteracyTrades/constructionNegotiaitonSalesCreativityTeamworkcritical thinkingLeadership/managingTime managmentProblem solvingCooking/culinaryComputer literacyGreat decision makerOrganized
Eligible
Eligibility(select all that apply)*

IncarceratedFormerly incarceratedVetranI am unemployedOn medicaidon probationon parolereceiving TANFReceiving SNAPI am 55(+)I have a misdemeanor convictionI have/had IEP/504 plan/ICAPI have/had a Substance use disorderHomelessI am undocumentedESLGang involvedI am 15-17I am 18-24I am 25 and up
Eligible(3 points to be eligible)
Suitable
Suitability #1 Choose all that apply*

I am willing to workI am willing to learn new skillsI am willing to help othersI am willing to work on my sobriety/if applicableI am not willing to work
(Suitability #1(need 3 points to advance)
BESI #1 I feel confident in my ability to communicate in a professional setting effectively*
BESI #2: I possess the necessary technical skills required for the job I am seeking*
BESI #3:I have access to reliable transportation to commute to work consistently*
BESI #4:I have a strong support system that encourages and supports my career goals*
BESI #5: I feel comfortable adapting to new technologies and software*
BESI #6: I have a stable and secure housing situation that allows me to focus on my employment*
BESI #7: I have access to affordable and reliable childcare services if needed*
BESI #8: I am confident in my ability to manage time effectively and meet deadlines*
BESI #9: I have received adequate training and education in my desired field *
BESI #10:I feel confident in my ability to handle work related stress and challenges*
BESI points(needs 27 points to advance)
Congruence
1. I enjoy helping others in my community by supporting their education, health, and job opportunities*
2. I am committed to improving myself through learning, staying healthy, and finding meaningful work*
3. I believe that being part of a strong and supportive community can help me and others achieve success.*
My values*

I'm pious(respectful & devoted)I'm LoyalI'm ReliableI'm about supporting communityI am none of these valuesI am honest
Congruence( needs 9-15points to be congruent)
Other Important Information
raffle number

BIO*

	NEVER	Rarely	Sometimes	Often	Always
I’ve used alcohol or substances (like weed, pills, or harder drugs) more than I meant to.
I’ve tried to cut back on substances but found it hard to stop.
I’ve had cravings or strong urges to use substances.
My substance use has gotten in the way of my responsibilities at work, school, or home.
I’ve continued using even though it’s caused problems with my health, mood, or relationships.
I’ve experienced withdrawal (headaches, anxiety, sweating, irritability, etc.) when I didn’t use.

What would you like to improve to be your best*
Choose the areas affected due to the issues marked above(mark all that apply)*

EmotionalMarriage/and or familyMentalSchoolPhysicalWorkSexualLegalSocialOtherN/A
Phone Number
Should be Empty:

Community Anchor Academy

Community Anchor Academy

Crisalida, Inc.

In my relationships(answer the following questions as in regards to current and previous relationships)

I have experience With..........

What I have or who I am.........

Medical History

Advance Childhood Experience (ACE)

PHQ 5 and GAD 7

Eligible

Suitable

Congruence