G.R.A.C.E. Initial Assessment
Personal Information
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Preferred Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Female
Male
Other
Preferred Pronouns
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Preferred Method(s) of Communication
*
Call
Text
Email
Background Information
Primary Concerns/Reasons for Seeking Services:
*
Are you currently experiencing any of the following? (Check all that apply)
Domestic violence or abuse
Homelessness or housing insecurity
Employment challenges
Substance use/recovery
Mental health concerns
Other
Do you have a primary care provider and/or therapist?
*
Yes
No
Would like one but need resources
Do you feel safe in your current environment?
*
Yes
No
Do you have access to a computer and internet?
*
Yes
No
Goals & Support
What are your primary goals for seeking support from G.R.A.C.E.?
What resources or services are you most interested in? (Check all that apply)
Housing assistance
Job training and employment support
Counseling or therapy
Legal aid
Financial literacy training
Peer support groups
Other
What barriers or challenges are you currently facing that would prevent you from meeting your goals?
Permissions & Agreements
Confidentiality Agreement
*
By checking this box, I understand that my information will be kept confidential and used solely for the purposes of providing services through G.R.A.C.E.
Consent for Communication
*
By checking this box, I consent to being contacted via my preferred communication method listed.
Release of Information
*
I consent to the sharing of necessary information with partner organizations to provide coordinating services.
I do not consent to the sharing of necessary information with partner organizations to provide coordinating services.
Disclaimer
*
By checking this box, I understand that G.R.A.C.E. offers support, education and resources, we are not medical professionals and cannot diagnose or treat medical or mental health conditions. Your health matters and we encourage you to connect with qualified healthcare providers for any medical needs.
Signature
*
Continue
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