DEMOGRAPHICS

Name *

Email *

Phone

Previous Address

City

Zip

Gender

Martial Status

Race

Ethnicity If Hispanic:

Primary Language

Religious /Spiritual Practice

Emergency Contact

Phone Number

Relationship

Emergency Contact Address

Social Security Number

LEGAL INFORMATION / HISTORY

Number Of Arrests In The Last 30 Days

Pending Cases

Previous Involvement with the Criminal Justice System?

Current Probation/ Parole

Probation/Parole Officer Name

Probation/Parole Officer Phone

HEALTH STATUS

Psychiatric Conditions:

Psychiatric Conditions

Are you currently taking medication for this

Addiction Disorders:

Illegal Substance Uses / Alcohol Abuse (Last 2 Years)

Currently Using

Medical Conditions:

Current Medical Conditions

Trauma / Abuse:

Any History Of Trauma / Abuse

HEALTH STATUS (Contd)

Prescribed Medications:

Current Medications

Smoker

Pregnant

Allergies: (Include medications)

Current Insurance Provider

Current Doctor/Clinician/Worker

Current Doctor/Clinician/Worker Phone

DRUG / ALCOHOL HISTORY

Drug(s) of Choice

Method

Age at first use

ENTITLEMENTS AND BENEFITS

Principal Source of Income

Benefits

Medicaid Status

OTHER STATE/PROVIDER AGENCY INVOLVEMENT

If so, what is your worker's name and phone number?

REFERRAL SOURCE

Who referred you to this house?

FAMILY AND SUPPORTS

Do you feel you have social supports (family, friends, etc)?

Yes

No

How would you describe your current relationship with your family members?

EMPLOYMENT STATUS

Employment Status

Highest Grade Completed

HOUSING STATUS

Living situation immediately prior to Thrive Together Residences

Have you been homeless within the last six months?

Yes

No

Are you at risk of homelessness?

Yes

No

How many of the last 30 days have you been in a controlled environment (i.e. jail, hospital, group home, etc.)?