NMD's Pre Placement Appraisal Attachment A Client's Name: Date: DOB: Birthplace: US citizen? Y/N Current Address or Placement: Social Worker or Probation Officer attending this meeting: County of Case Origination: Contact information: Client's Statement of Interest and Intent: "I am here today because... Client describes his goals and challenges: "What I really want to do is... Client describes his fears and concerns: "What stops me from moving forward is...
Accounts: O [ have a savings account Name of Bank:: Current Balance: $ I have a checking account Name of Bank:: Current Balance: $_ I I I have a credit card Name of Card: Current Balance: $ Current Financial Information Outstanding Debt ancl Bills: O Monthly Cell phones charges HH Monthly Car Payments [~1 Monthly Car Insurance H Other Loans Health Insurance Q Unpaid taxes D Other Income Sources: O Child Support Q Employment Income O Food Stamps O General Public Assistance O Medicaid HH No Financial Resources HH Section 8 Housing Q State Children's Health Insurance Program O Social Security G Social Security Disaioiiity Insurance (SSDI) Q Supplemental Social Security Income (SSI) G Temporary Aid-Needy Families (TANF) O Unemployment Benefits [Zl Veterans Benefits O Veterans Healthcare D Other: _^ ^^_ Work History Work history : (List all past work experiences) From Employer_ Address Position/Title to Salary per hour $ Average hours per week Supervisor Phone Duties/Skills Reason for Leaving Would they hire you back? Why or why not From Employer_ Address Position/Title to Salary per hour $ Average hours per week Supervisor Phone Duties/Skills Reason for Leaving Would they hire you back? Why or why not_
Information on the important people in my life (Permanent Connections) 1. 2. Name Address Contact phone number Name Address Contact phone number Name Address Contact phone number Legal Information Arrest Status: I I have been arrested! have never been arrested D Jailed O Juvenile Hall O Detained l~~l Restitution Please list your arrest history: Date Age Charge What Happened? Probation Officer Commitment Length Medical Information Do you have any allergies? Please describe: Please list all of the medications you are currently taking: Medication Name Frequency Doctor Diagnosis Date Started Current Doctor: Name: Address: When was your last visit?
Counseling: 0 I arn currently seeing a counselor. Counseling History Past Counseling: O I have seen a counselor in the past. Counselor Information: Name: Agency: Location: Date Started: 1 am still having these problernss: Counselor Information: Name: Agency: Location: Date Started: Date Ended: Critical Issues Have you ever been the victim of the following abuses? If yes, please explain briefly O Emotional Abuse Q Neglect G Physical Abuse O Sexual Abuse dl Sexual Assault Personal Belongings If you are accepted into THP+FC what would you bring with you? (Please list each item) Furniture PI Decorations
I I Stereo Equipment 1 1 Appliances d] Vehicles (Must have current Driver's License, registration, and insurance) D Other Additional Questions What do you know about THP+FC and how do you think it can help you? What steps have you taken to prepare yourself for THP+FC? Have you had training in independent living skills? What are your best independent living skills? What would you like to do in the future to earn money and support yourself? How do you dea! with stress? Describe what types of behaviors you have when you are stressed. Have you ever been fired from a job? Yes No If so, explain why you were fired.
How do you deal with authority figures? (Example: teachers, law enforcement, bosses, staff, etc.) How do you deal with peer pressure? How well do you get along with others? How do you think the THP+FC can help you to become more self-sufficient? Additional Information: