Casa de Belen Pre-Intake
Below is a set of questions that allows Casa de Belen to get to know you/the youth a little bit better. The answers to this pre-intake will allow us to help you in the best way possible.We appreciate your honesty and openness but you are not required to answer questions that make you feel uncomfortable.
Todays Date *
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Time *
Time
:
Person filling out pre-intake *
Your answer
Relationship to Youth *
Required
Location while filling out pre-intake *
Required
Legal Name (first, middle, last) *
Your answer
Preferred Name *
Your answer
Phone Number
Your answer
Email Address
Your answer
What is the safest/best way to reach you? *
Required
Best days and time to contact you *
Required
Date of Birth(Day Month Year) *
Your answer
What is your current age?
Your answer
Social Security Number (write in 'I don't know' if SSN is unknown) *
Your answer
How did you hear about Casa de Belen? *
Required
Legal Parents Name- if over 18, write N/A (We will not contact them without talking to you first) *
Your answer
Legal Parents Phone Number- if over 18, write N/A *
Your answer
Legal Parents Address- if over 18, write N/A *
Your answer
Have you ever lived at Casa de Belen *
If yes, when?
Your answer
Where are you currently living? *
Required
Thinking about where your staying right now, is anything happening that scares you? *
Thinking about where you're currently staying- how long are you allowed to be there? *
Required
How many places have you lived during the last year? *
Required
Last address you lived for at least 6 months?
Your answer
How long were you at this residence?
Your answer
What is the last date you stayed at this residence?
Your answer
What are your religious/spiritual preferences? *
Required
Is there a specific gender you identify as? *
Required
What is your sexual orientation? *
Required
What race do you identify as? Check all that apply *
Required
Are you enrolleable in a Native American Tribe? *
If yes, what tribe?
Your answer
When it comes to ethnicity do you identify as: *
Required
Could you please give some details about your living situation? For example; how long you've lived there, who you live with, how long you can continue living there, etc. *
Your answer
Mark all the statements below that apply to you? *
Required
Do you have a mental health history? This question is asking if you've ever seen a counselor to talk about how you feel (not including a regular school counselor?) *
If yes, please explain:
Your answer
Have you ever used drugs/substances? (check all that apply-Casa will help you no matter how you answer this question) *
Required
Prior drug use details (type, how long ago, how often)
Your answer
Are you currently using? (type, how often, how long) Reminder- we will still help you :)
Your answer
Have you ever physically hurt someone else out of anger, or thought of hurting others? *
Required
If yes, please explain:
Your answer
Do you ever set things on fire? *
Required
If yes, please explain:
Your answer
Have you ever done any if the following? Check all that apply *
Required
If yes, please explain:
Your answer
Have you had any self-harming behaviors in the last 6 months? This questions is asking if you ever hurt your body on purpose when your sad, mad, anxious or stressed. (Casa will help you no matter how you answer this question) *
Required
If yes, please explain:
Your answer
Have you ever had thoughts of killing yourself? *
Required
If yes, have you thought of how you would end your life? *
Are you interested in only day-services or living at Casa (living at Casa includes all day services)? *
When would you like us to contact you? *
Is there anything else you would like us to know?
Your answer
Are you staff, professional or a volunteer filling out this form? *
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