• Control the Fire© Anger Management Program for Court-Ordered Clients (CTFCOC) Intake Form

    Thank you for choosing the CTFCOC program offered by Divine Revelations Ministries, Inc. (DRMI). This form is for individuals who have been court-ordered to complete anger management classes approved by the 2nd Judicial Circuit of Florida. Please complete all applicable fields and sign at the end.

  • Intake Identification

  • Date Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Additional Information

  • Demographics and Household

  • Race
  • Marital Status
  • Living Situation - Household composition
  • Living Situation - Housing type
  • Your highest grade completed

  • Employment

  • Format: (000) 000-0000.

  • Medical and Mental Health History

  • Do you have any ongoing health issues?*
  • Are you currently taking any medications?*
  • Were you ever treated for psychological or emotional issues?*
  • Did you complete the program?*
  • Have you ever been prescribed medication(s) for psychological or emotional problems*

  • Mental Health Screening

  • Have you experienced serious depression or other emotional issues in the past 30 days*
  • Have you experienced serious depression or other emotional problems in your lifetime*
  • Have you experienced serious anxiety or tension?*
  • Have you experienced ever experienced hallucinations?*
  • Have you experienced trouble understanding, concentrating, or remembering?*
  • Have you experienced trouble controlling violent behavior?*
  • Are you feeling suicidal today?*
  • Have you had thoughts of suicide in the past 30 days?*
  • Have you ever attempted suicide?*
  • Have you ever felt like hurting others or committing homicide?*

  • Substance Use History

  • Have you ever drank alcohol or used legal/illegal drugs?*
  • Do you need help for alcohol or drug abuse/dependence*
  • Have you ever received a DUI or DWI?*
  • Have you ever received treatment for alcohol or drug abuse/dependence?*
  • Have you noticed connections between alcohol or drugs and anger/aggression?*

  • Family Background

  • By whom were you raised?
  • Parents or guardians living or deceased
  • Did you have any childhood traumatic events that you remember?
  • As you can remember, were you or your siblings abused as children?
  • Relationship with your father
  • Relationship with your mother
  • Should be Empty: