Emergency Services Intake Assessment Emergency Services Intake Assesment Date Interviewer* First Last Client* First Last Phone Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referral Source Phone No. Referred ForEmergency Contact* First Last Emergency contactEmergency Contact PhoneRelationship* Age Date of birth MM slash DD slash YYYY Race Black or African-American American Indian or Alaska Native Latino/a or Hispanic White or Caucasian Native Hawaiian or Other Pacific Islander African Caribbean Decent Other Choose your racePersonal InformationName* First Last Your nameAge* Who do you live with?* How Long?Are you in State custody? Yes No How Long?Why?Reason for being in State custodyName of Foster parent Name of person in your chargeFoster Agency General InformationDid you graduate high school? Yes No What School? Applies to high school graduatesIf still in school, what grade?Please enter a number from 1 to 12.Applies to high school graduatesAre you behind Yes No How many? If you are behind If you are behindHow many?Please enter a number from 1 to 15.If you are behindIf No, what was the last grade you completed?Please enter a number from 5 to 12.Do you plan to return to school? Yes No If no Get GED Attend Job Corp What School do you attend? If you are currently in schoolGPAPlease enter a number from 0 to 7.Grade Point Assessment(If you are in school)Have you ever been suspended? Yes No If you are in schoolIf Yes, how many times?Please enter a number from 1 to 10.Why?If you have ever been suspendedDo you plan to attend: College Trade School What would you like to become? AmbitionIncomeWorkFamily FirstSSIChild SupportOtherIf employed, where? How Long?(years)Please enter a number from 1 to 50.If employedJob nature Full Time Part time What is your position? If employedDo you like your job? Yes No I don't know PERSONAL QUALITIESWhat do you enjoy doing?*How would you describe yoursef?*What do you like about yourself?*What do you dislike about yourself?*Do you get depressed? Yes No If yes, when? Do you have close friends? Yes No What do you do with them?If you have close friendsDo you have a support system? Yes No If yes, who? FAMILY OF ORIGINWho raised you? First Last Where did you live during childhood?* Are your parent’s deceased or incarcerated? Yes No If Yes, ExplainWere there problems in your home such as: Drug abuse Alcoholism Physical abuse Sexual abuse Emotional abuse Arrests Mental illnesses Criminal activity Others Were these problems with your: Mother Father Siblings Self Others Do you know your biological father? Yes No If yes, does he participate in your life? Yes No Was she/he a good parent? Yes No If no, ExplainHow do you feel about them now?How were you disciplined and by whom?*How many siblings do you have?Where are you in the birth order?What was it like growing up in your family?*Are you emotionally close to your family? Yes No Do you have close contact with your sibling? Yes No PERSONAL RELATIONSHIPAre you in a new relationship? Yes No Do you live together? Yes No Describe the relationship?Does he/she assist you financially? Yes No How does he/she behave when he/she is angry? What happens when you and he/she fight or disagree? Has he/she ever hit you? Yes No DOMESTIC VIOLENCEHave you ever been: Verbally abused Sexually abused Physically abuse ANGERWhat kinds of things make you angry?*Have you ever physically harmed anyone Hit Kicked Punched Slapped Stabbed Shot Have you ever been arrested? Yes No If yes, how many times?What age?(years)Please enter a number from 1 to 99.What were the charges? What kinds of things make you sad? Have you ever felt that life was not worth living? Yes No Have you ever had self-destructive or suicidal thought? Yes No Have you had recent suicidal thought? Yes No Have you ever formed a suicidal plan or attempted to commit suicide? Yes No Have you ever had homicidal thoughts (harming others)? Yes No FUTURE PLANSWhere would you like to be in 5 years?* SPIRITUAL HISTORYDo you believe in God? Yes No Do you have a religious preference? Yes No What is your preference? Are you a participating member of a Church?* Yes No Who is your role model/mentor? Why? What are your greatest needs at this time?*Do you have Transportation? Yes No Who? COMMENTSEnter your commentsWIND, CDC Client Participation and Accuracy Statement* I agree to the privacy policy.I have answered all the questions completely and honestly. I understand that the information I have provided is confidential pursuant to Federal and State regulations, except when mandatory reporting is required in the disclosure of previously unreported sexual or physical abuse, intent to harm another or myself.* I agree.Date* MM slash DD slash YYYY
