Briarpatch Street Outreach Needs Assessment
Please answer as many questions as possible. Once submitted our staff will review and follow up to schedule an intake for services due to an increase in referrals it may take 3-7 business days for us to respond.

If you would like to visit us at the Beacon, 615 E Washington Ave, Madison, WI 53703 we have staff hours on Monday from 9am - 11am, Wednesday 9am - noon, and Friday 9am - 11am.
Name (First & Last) *
Preferred name *
Preferred pronouns
Clear selection
How did you hear about Briarpatch Street Outreach?
Did you age out of Foster Care or Juvenile Corrections?
Clear selection
Are you safe?
What is your age?
Clear selection
What is your preferred language?
Clear selection
What is the best way to communicate with you? *
Phone number *
email address
Can we text you? *
What is your preferred gender identity?
Clear selection
Are you currently pregnant?
Clear selection
Do you have children?
Clear selection
Where are you sleeping most frequently?
Clear selection
Do you feel like you are getting enough sleep?
Clear selection
Is your current housing situation stable?
Clear selection
How long can you stay at your current housing?
Clear selection
If necessary, would you sleep in the Emergency Shelter?
Clear selection
Would you say that you have enough to eat?
Clear selection
Do you have Foodshare?
Clear selection
What forms of transportation do you use?
Clear selection
Do you have a drivers license?
Clear selection
What forms of ID do you have? *
Required
Do you have any legal issues going on right now? (on papers, owe money to court, pending charges, etc.)
Clear selection
What is your current work / income?
What is your school situation?
Clear selection
Do you have health insurance / Badgercare
Clear selection
Are their medications you take or should take?
Clear selection
Are you experiencing any health concerns? Do you feel like you need to see a doctor?
Clear selection
Are you experiencing any tooth or mouth pain / issues?
Clear selection
Have you been in a situation where you felt like you were sexually exploited or exploited for money, food, shelter?
Clear selection
How many times have you been physically threatened or physically harmed
Have you made attempts to kill yourself?
Clear selection
Have you thought about harming yourself or thought you'd be better off dead?
Clear selection
Have you been hospitalized for harming yourself?
Clear selection
Have you thought about or attempted to harm someone else?
Clear selection
Do you feel?
Are you using controlled substances? (drugs, alcohol)
Are you concerned about your use?
Clear selection
Have you been a victim of crime?
What do you feel is the most important thing we should know about you?
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