Referral Agency: Applicant referred by: (First) (Middle) (Last) Date of Birth: / / Age: Sex: Preferred Gender:

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Justina Martin
7 years ago
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1 Youth Services TRANSITIONS PROGRAM (Young Adult Referral 16 to 24) 311 S. Madison Ave. Tulsa, OK Referral Agency: Date: Applicant referred by: Phone #: PERSONAL INFORMATION Name: (First) (Middle) (Last) Street Name and/or Preferred Name: Phone: ( ) Date of Birth: / / Age: Sex: Preferred Gender: Race/Ethnicity: If American Indian, please indicate which tribe: Social Security #: - - Are you a U.S. Veteran? Yes No Do you have (or have you ever had) Medicaid or Health Insurance of any kind? Yes No I don t know If yes, what coverage? (Insurance Company Name or Medicaid #) Are you currently Homeless? Yes No I don t know If yes, where are you staying? Couch Surfing w/ Friends Community Shelter Camp Site outside/other/unknown If you are not currently homeless, please list where you live: Address: City: State: Zip: IF YOU ARE UNDER 18 YEARS OLD: Who is your Parent or Legal Guardian? Name: (First) (Middle) (Last) Address: City: State: Zip: Phone: ( )

2 PREGNANT AND/OR PARENTING YOUTH: Are you currently pregnant or expecting a child? Yes No I don t know If Yes, when is the child due? If Yes, is the child s mother/father currently involved? Yes/No/Sometimes If Yes, what is the name of the child s mother/father? Age: Do you currently have any biological children in YOUR full-time legal custody? If Yes, how many children? If Yes, Please list names and ages: Do you currently have any biological children that are NOT in your full-time legal custody? If Yes, how many children? If Yes, Please list names and ages: If Yes, who is the child/children staying with? If Yes, do you have a legal plan to regain custody? Yes/No/I don t know Do you HAVE any of the following? (Check all that apply) TANF WIC OBGYN/Doctor Child First Program Support Parenting Classes MENTAL HEALTH Have you ever been diagnosed with any of the following (check all that apply): ADD/ADHD Depression Anxiety PTSD Bi-Polar Schizophrenia Other Do you currently (within the last 6 months) have a mental health care doctor and/or counselor? Yes No I don t know (Examples: Family & Children s Services FCS, Counseling & Recovery Services CRS, etc.) If yes, where do you go, and who do you see? If no, would you be willing to see someone? Yes No I don t know Are you currently (within the last 6 months) taking any mental health medications? Yes No I don t know If no, do you feel you should be taking medications? Yes No I don t know If yes, please list your current medications: More: SUBSTANCE USE / ABUSE Do you currently have any substance abuse challenges? Yes No I don t know If yes, please check all the substance(s) you struggle with: Alcohol Marijuana Synthetic Marijuana ( K2, etc.) Methamphetamines Prescription Medication Hallucinogens Other Would you be willing to see someone to address this challenge? Yes No I don t know

3 PLEASE TELL US Were you ever in DHS custody? Yes No I don t know Currently in DHS Custody If yes, where and for how long? Were you ever in OJA/Detention Center? Yes No I don t know Currently in OJA Custody If yes, Why? If yes, are you currently on probation? Yes No I don t know If yes, who is your probation officer? Are you currently involved in any of the following? Adult Judicial System Adult Drug Court Adult Mental Health Court Do you currently owe money for court fees, fines, probation, etc.? Yes No I don t know If yes, how much do you currently owe? EDUCATION: Name of Last School Attended: Check the box with the highest grade you have completed: 6 th -8 th Grade 9 th Grade 10 th Grade 11 th Grade 12 th Grade High School Diploma GED Some College MISCELLANEOUS: Do you NEED any of the following? (Check all that apply) Driver s License OK photo ID Social Security Card Birth Certificate Health Care Provider Food Handler s Card Food Stamps Health Insurance Yes I Can Benefits SSI/SSDI TANF OTHER Do you HAVE any of the following? (Check all that apply) Driver s License OK photo ID Social Security Card Birth Certificate Health Care Provider Food Handler s Card Food Stamps Health Insurance Yes I Can Benefits SSI/SSDI TANF OTHER Do you have access to reliable transportation? (Check all that apply) I ride Tulsa Transit (Bus) I have a car WITH INSURANCE I have a car NO INSURANCE I walk I ride a bike I don t have access to transportation at all

4 SOCIAL SKILLS I can wake up on my own in the morning: YES NO Sometimes I need extra help Don t Know I can keep an apartment clean and safe: YES NO Sometimes I need extra help Don t Know I can shower daily and keep myself clean: YES NO Sometimes I need extra help Don t Know I can be on time to appointments: YES NO Sometimes I need extra help Don t Know I can get along with my peers: YES NO Sometimes I need extra help Don t Know I can get along with my case-manager: YES NO Sometimes I need extra help Don t Know I can get along with my teachers: YES NO Sometimes I need extra help Don t Know I can get along with my boss: YES NO Sometimes I need extra help Don t Know I can get along with my co-workers: YES NO Sometimes I need extra help Don t Know I can get along with my roommates: YES NO Sometimes I need extra help Don t Know I can get along with police: YES NO Sometimes I need extra help Don t Know INDEPENT LIVING SKILLS I can find a job: YES NO Sometimes I need extra help Don t Know I can KEEP a job: YES NO Sometimes I need extra help Don t Know I can budget my money: YES NO Sometimes I need extra help Don t Know I can go to the store and buy groceries: YES NO Sometimes I need extra help Don t Know I can cook for myself: YES NO Sometimes I need extra help Don t Know I can use a bank: YES NO Sometimes I need extra help Don t Know I can keep myself safe: YES NO Sometimes I need extra help Don t Know I know what to do if I get sick: YES NO Sometimes I need extra help Don t Know I can use Tulsa Transit: YES NO Sometimes I need extra help Don t Know RISK FACTORS (check all that apply to you): Runaway Intentionally Hurts Animals Isolation from Family & Friends Self-Abusive Behavior Recent drastic changes in sleeping patter Set Fires Recent drastic changes in eat habits Involvement in Criminal Activity History of Neglect Difficulty maintaining employment Inappropriate Sexual Behaviors Difficulty maintaining safe housing Perpetrator of Sexual Abuse Chronic Illness Victim of Sexual Abuse History of Inpatient Psychiatric Hospitalizations Victim of Physical Abuse RISK FACTORS (check all that apply to your family): Use/Abuse of Drugs Chronic Physical Illness in Family Use/Abuse of Alcohol Family History of Mental Illness Attempted Suicide Family History of Psychiatric Hospitalizations Suicidal Thoughts Family History of Substance Abuse Hallucinations Parental Incarceration Repeated lying, stealing, or property damage History of Domestic Violence Physical Aggression towards others Poverty Intentionally Hurts Others Young Adult Exposed to substance abuse

5 EMPLOYMENT: Have you ever had a job? Yes No If Yes, where have you worked before? Do you currently have a job? Yes No If yes, where are you working? If yes, what is your schedule? If No, do you need extra help finding and/or keeping a job? Yes No I don t know PLEASE TELL US What makes you WANT the Transitions Program? What are some of your specific goals you d like to work on with a case-manager? Applicant s Signature \ Please return completed form to: Youth Services Transitions Program 311 S. Madison Ave. Tulsa, OK Fax: Date

SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM

SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM (This form must be completed within 30 days of program entry) IDENTIFYING INFORMATION Date Information is Gathered: 1. Applicant Last Name: First Name: