Language
English (US)
Spanish (Latin America)
TEAM Screening Assessment
Purpose: To quickly identify participant strengths, immediate needs, barriers, risks, and service priorities using a trauma-informed, culturally empathetic approach.
SECTION 1: PARTICIPANT IDENTIFICATION
Full Name
*
Preferred Name
Pronouns (select all that apply)
She/Her
He/Him
They/Them
Ze/Zir
Other
Pronouns - Other
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Method of Contact (select all that apply)
Phone
Text
Email
Other
Preferred Method of Contact - Other
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
SECTION 2: IDENTITY & CULTURAL CONSIDERATIONS (Voluntary)
Gender Identity (select all that apply)
Woman
Man
Non-binary
Transgender
Two-Spirit
Other
Gender Identity - Other
Sexual Orientation
Primary Language(s)
Interpreter Needed
Yes
No
Cultural/Community Affiliations
SECTION 3: TRAUMA & SAFETY SCREENING
Trauma & Safety Experiences (select all that apply)
Domestic violence
Community violence
Loss/bereavement
Displacement
Other
Current Safety Concerns (select all that apply)
Physical safety
Emotional safety
Environmental risks
Other
If yes, please describe (safety concerns)
Do you feel safe where you are currently living?
Yes
No
SECTION 4: ESSENTIAL NEEDS
Housing Status (select all that apply)
Stably housed
Unstably housed
Homeless
Shelter
Other
Food Access (last 30 days)
Enough food
Sometimes not enough
Often not enough
Income Source(s) (select all that apply)
Employment
Benefits
Family support
No income
Other
Monthly Income (approx.)
SECTION 5: ACCESS & SUPPORTS
Health Insurance (select all that apply)
Private
Public
Uninsured
Primary Care Provider
Yes
No
Gender-Affirming Care Access
Yes
No
Not applicable
Legal Document Needs (select all that apply)
ID
Birth certificate
Name change
Other
Support System (select all that apply)
Family
Friends
Community
None
SECTION 6: MENTAL & PHYSICAL WELLNESS
Mental Health History (select all that apply)
Depression
Anxiety
PTSD
Other
Mental Health History - Other
Current Mental Health Services (select all that apply)
Therapy
Medication
None
Substance Use (last 6 months) (select all that apply)
Alcohol
Drugs
None
Other
Substance Use - Other
Physical Health Concerns
Felt hopeless or overwhelmed (past 30 days)
Yes
No
Had thoughts of harming yourself (past 30 days)
Yes
No
Made a plan to harm yourself (past 30 days)
Yes
No
If YES to any (safety actions taken)
Safety plan created
Referred to crisis services
Other
SECTION 7: STRENGTHS & GOALS
Personal Strengths (select all that apply)
Resilience
Adaptability
Social skills
Problem-solving
Other
Personal Strengths - Other
Participant-Identified Goals
SECTION 8: SCORING & SERVICE PRIORITY (Staff Use Only)
Scoring: Trauma/Safety
Please Select
Low
Moderate
High
Scoring: Housing/Food
Please Select
Low
Moderate
High
Scoring: Health/MH
Please Select
Low
Moderate
High
Scoring: Access/Legal
Please Select
Low
Moderate
High
Scoring: Support System
Please Select
Low
Moderate
High
Overall Priority Level
Please Select
Low
Moderate
High
SECTION 9: REFERRALS & NEXT STEPS
Referrals Made (select all that apply)
Housing
Food assistance
Mental health
Substance use
Legal
Other
Follow-Up Date
-
Month
-
Day
Year
Date
Staff Name & Signature
Date Completed
-
Month
-
Day
Year
Date
Submit Assessment
Submit Assessment
Should be Empty: