Dupree Living Solutions LLC Intake Assessment Questionnaire
Applicant Name
*
First Name
Last Name
Date of Assessment
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
*
With family
Homeless
Shelter
Transitional housing
Other
Able to manage daily routine?
*
Yes
No
If No, please explain
Able to clean and maintain living space?
*
Yes
No
Okay with shared living?
*
Yes
No
Able to cook or prepare meals?
*
Yes
No
Currently working/in school/in program?
*
Yes (specify)
No
Looking for opportunities
If yes, please describe
Takes prescribed medications?
*
Yes
No
Takes medications independently?
*
Yes
No
Medical conditions?
*
Yes
No
If yes, please describe
Receiving mental health support?
*
Yes
No
Alcohol use?
*
Yes
No
Marijuana use?
*
Yes
No
Other drugs use?
*
Yes
No
Any Nicotine products
*
Yes
No
Substance use description
Willing to live in drug/alcohol/smoke-free environment?
*
Yes
No
Substance abuse treatment program?
*
Yes
No
If yes, when and where?
Violent behavior or aggression history?
*
Yes
No
If yes, please explain
Do you have any legal history? Arrest? Charges? Time Served?
*
Yes
No
If yes, please explain
Able to follow a curfew? Unless approved
*
Yes
No
No visitors/overnight guests?
*
Yes
No
Participate in chores?
*
Yes
No
Attend meetings/check-ins?
*
Yes
No
Accountable for actions?
*
Yes
No
Open to staff feedback?
*
Yes
No
Any pets?
*
Yes
No
Motivation
Short-term goals
Long-term goals
Support needed
Current source of income?
*
Yes
No
Income source
Employment
SSI/SSDI
Family
Assistance
Other
Monthly income
Able to afford program fee?
*
Yes
No
Unsure
Financial obligations?
*
Yes
No
If yes, please explain
Submit
Should be Empty: