Little Fannies Client Self Assessment/Evaluation
Please answer all the questions truthfully. We are here to offer assistance to you. Someone will contact you within 24 - 48 hours after receiving your self assessment. All your answers and information you provide to us on this assessment/evaluation form will be treated in the strictest confidence and will only be discussed with the board members of Little Fannie's Heavenly Housing with the intentions of providing supportive services to you and will not be divulged to any outside third party without your consent.  If we take you on as a client and find any discrepancies in your answers we have the right to withdraw you from our program.  
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First and Last Name *
Today's Date *
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Phone Number *
Do You Have State ID or Drivers License? *
What Complete Address Is On Your ID
Do you have a email address? *
If Yes, Please enter valid email address
Date of Birth *
MM
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DD
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YYYY
Gender *
Required
Marital Status *
Required
Victim of Domestic Violence *
Required
Do You Have Children? *
Required
If Yes, How Many Children Do you have? *
What Are the Ages of Your Children? *
Do You Have Any Pets? *
Are you a U.S. citizen? *
Required
Have you ever been sexually abused or a victim of sex trafficking? *
Required
Do you have a car? *
Required
Do you have a case manager or social worker? *
Required
If Yes, Case Manager or Social Worker Name & Phone
Do you have any disabilities? *
Do you use any recreational drugs or alcohol? *
If Yes, What is your drug of choice?
Where did you spend last night? *
Length of stay in location provided in previous question? *
Housing Status *
Do feel threaten in your living situation? *
Do you have or ever had Section 8/Subsidized Housing? *
Are you currently taking medication for any health concerns? *
If yes, Can you afford your medication? *
Please identify if any of the listed conditions exist. *
Homeless Status *
Have You Been In Contact With Any Homeless Shelters?
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If Yes, What Shelter and Who Did You Speak With
Are you employed or have a income? *
If Yes, How much do you make weekly?
Do you have your high school diploma or equivalent? *
Are you in a relationship? *
Do you have any legal issues? *
Do you ever think about hurting yourself or committing suicide? *
Do you get upset easily or have anger issues? *
Do you have trust issues? *
Are you depressed? *
Do you have outside family/friend support? *
What services are you looking to receive from our organization to help with your current situation? *
If we can't provide the services you are seeking, are you okay with us referring you to other resources/agencies that will be able to support your needs? *
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