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Pre-assessment Screening Form
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* Indicates required question
Please note: We are not currently equipped to accept women with other children in their care.
Contact Information
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
Your answer
Email Address
Your answer
Housing
Current or Most Recent Living Situation
*
Your answer
Education
Where did you attend high school?
*
Your answer
Highest grade completed?
*
Your answer
Did you graduate?
*
Yes
No
Received GED
Other:
Did you attend college?
*
Yes
No
If Yes, Where?
*
Your answer
Have you received any specialized training? Please explain.
*
Your answer
Employment History
Number of jobs held in the past year?
*
Your answer
Reason no longer employed (if applicable)
Your answer
Additional work skills you may have
*
Your answer
Work Attitude and Habits
How do you see yourself in the workplace?
*
Your answer
What kind of employee do you consider yourself?
*
Your answer
Are you seeking any job skills (i.e. writing resumes, job interview techniques, etc.)?
*
Your answer
Medical History- Last Exams
What was the date of your last physical?
*
MM
/
DD
/
YYYY
Findings
*
Your answer
Due Date
*
MM
/
DD
/
YYYY
What was the date of your last dental visit?
MM
/
DD
/
YYYY
Findings
Your answer
What was the date of your last vision check?
MM
/
DD
/
YYYY
Findings
Your answer
What actions do you feel are needed to improve your physical health?
*
Your answer
Mental Health History
Check each category that has (ever) been experienced.
*
Depression
Mental Illness
Sexual Abuse
Physical Abuse
Emotional Abuse
Suicidal thoughts/attempts
Treatment for any of the above
Other:
Required
Legal History
Do you have a valid driver's license?
*
Yes
No
If no, why not?
*
Your answer
If no driver's license, do you have a photo I.D.?
*
Yes
No
Do you have car insurance?
*
Yes
No
If yes, insurance information:
*
Your answer
Do you have an arrest record?
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Yes
No
If yes:
Charge:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Conviction
*
Your answer
Sentence
*
Your answer
Charge:
Your answer
Date:
MM
/
DD
/
YYYY
Conviction
Your answer
Sentence
Your answer
Charge:
Your answer
Date:
MM
/
DD
/
YYYY
Conviction
Your answer
Sentence
*
Your answer
Have you been to drug court?
*
Yes
No
If Yes, Date and Sentence
Your answer
Probation/Parole Officer (if applicable)
Your answer
Phone:
Your answer
Upcoming Court Dates:
Your answer
Substance Abuse
Do you drink alcohol?
*
Yes
No
If yes, how often?
Your answer
Do you use prescription drugs?
*
Yes
No
Do you use street drugs?
*
Yes
No
Do you smoke or vape?
*
Yes
No
History of any substance use:
*
Your answer
Are you clean/sober?
*
Yes
No
If so, how long?
Your answer
Are you involved in a recovery program?
*
Yes
No
Do you have any substances in your system now?
*
Yes
No
Are you opposed to random drug and alcohol tests?
*
Yes
No
Domestic Violence
Are you involved in a domestic violence situation?
*
Yes
No
If yes, physical, emotional, verbal, or sexual?
Your answer
Are you in fear for your safety?
*
Yes
No
Who is your perpetrator?
*
Your answer
Family/Social Support
Are your parents involved?
*
Yes
No
If you have siblings, are they involved?
Yes
No
Clear selection
Is anyone else involved?
*
Yes
No
If yes, who?
Your answer
What are your interests/hobbies?
*
Your answer
Are you involved in any organizations (school, church, service)?
*
Your answer
Social Services History
Please check the agencies you are working with or have worked with in the past:
*
Adult and Family Services
Food Stamp Program
Services to Family & Children
Disability Services
Mental Health
Support Enforcement
Veterans Administration
Vocational Rehabilitation
Social Security Administration
Employment Office
Parole and Probation
Housing Authority
Other:
Required
The following services are provided for your benefit. Please check the top three (3) in order of priority:
*
Social Skills
Problem-solving Skills
Housing/Independent Living
Parenting Skills
Personal Counseling
Job Improvement
Health/Nutrition Information
Money Management
Education/GED
Legal Services
Job Training
Housekeeping Skills
Drug/Alcohol Counseling
Other:
Required
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Your answer
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