Welcome

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Full Name
First Name
Last Name
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Date Of Birth
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Location
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Phone Number
Please enter a valid phone number.
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Email
example@example.com
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Emergency Contact Name & Relationship:
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Emergency Contact Phone Number:
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NPI Number (if applicable):
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Please indicate your relationship to the person receiving services:
Self
Family Member
Guardian
Case Manager
Other
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Needs and Goals AssessmentPlease describe your primary reason for seeking habilitation services at this time. (What brings you here?)
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What specific skills or areas of daily living would you like to focus on?
Skill Development (e.g., decision-making, time management)
Behavioral Support (e.g., coping with dysfunctional behaviors)
Community Inclusion (e.g., social interaction, navigating the community)
Other
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What are your primary goals for these services?(Please be as specific as possible. For example: "I want to improve my social interaction skills to make new friends.")
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What are the biggest challenges or barriers you are currently facing that prevent you from reaching your goals?
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Do you currently receive services from any other agencies or professionals? If so, please list them.(e.g., therapists, case managers, other habilitation workers)
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Is there any other information about your health or background that you believe is important for me to know?(e.g., medical conditions, previous diagnoses, cultural considerations)
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Skill Development:On a scale of 1 to 10 (with 1 being very challenged and 10 being very confident), how do you currently rate your ability to make decisions and enhance your general performance levels? Please explain your rating.
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Behavioral Support: Have you noticed any dysfunctional behaviors that you would like to work on? What do you believe are the internal roots or triggers for these behaviors?
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Community Inclusion: Do you feel an integrated sense of self and connection with your environment and community? Yes or No. If no please explain.
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Authentic Self-Expression: The "Go Within" philosophy is about finding a safe space to authentically express yourself. What does "authentically express yourself" mean to you? How do you currently do this, or where do you feel held back?
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Personal Agency & Resilience: My work is about helping you cultivate an inner source of meaning and worth. What does "resilience" mean to you in your daily life? Can you recall a time when you had to be resilient?
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