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Intake Form

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Intake Form

Demographics

Name

First Last

Date of Birth

MM slash DD slash YYYY

Age at Enrollment Interview

Please enter a number from 1 to 150.

Gender

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Children

Are you currently pregnant?

Yes

No

Are you receiving prenatal medical care?

Yes

No

How many children do you have?

Please enter a number from 0 to 25.

How many children are under the age of 18?

Please enter a number from 0 to 25.

How many children are living with you?

Please enter a number from 0 to 25.

How many children are living in someone else's care?

Please enter a number from 0 to 25.

How many children are living with someone else due to a child protection court order?

Please enter a number from 0 to 25.

For how many children have you lost parental rights?

Please enter a number from 0 to 25.

Education/Employment

Education

Are you currently enrolled in school? (if the student is on summer break and plans to attend school in the fall, please enter "yes")

Yes

No

What is the highest grade in school that you have completed?

Are you currently enrolled in school or a job-related training program?

Yes

No

Are you current enrolled in a job-related training program?

Yes

No

Are you a full-time student?

Yes

No

Are you a full-time student in the training program?

Yes

No

Are you currently employed?

Employed Full-Time

Employed Part-Time

Self-employed

Not employed but looking for work

Not employed and not looking for work

Disabled

Retired

Volunteer Work

Other

During the past 30 days, how much money did you receive from:

Wages

Public Assistance

Disability

Total Received

Criminal Justice

In the past year, how many times have you been arrested?

How many of these arrests involved alcohol and/or drug use?

In the past year, how many nights have you spent in jail/prison?

Have you every been convicted of a felony?

Yes

No

Are you currently awaiting charges, trial, or sentencing?

Yes

No

Are you currently under legal supervison?

Yes

No

If yes, please specify type of supervision

Parole

Probation

Other

Housing

In the past 30 days, where have you been living most of the time?

Shelter

Street/outdoors

Institution

Housed

If housed, where?

Own/rent

Someone else's

Dormitory/college residence

Halfway house

Sober living residence

Residential treatment

Other

Substance Use Disorder (SUD) Treatment

Number of times in SUD Treatment

Are you currently:

Self-Help / Social Support

How many times in the past 30 days have you:

Attended self-help groups for recovery (such as AA, NA, etc.)

Met with a Sponsor Affiliated w a self-help group

Met with a peer recovery coach

Other type of self-help? Please specify

In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery?

Yes

No

Health Care

Are you currently covered by

No insurance

Private insurance

Medicaid

Medicare

VA

CHIP-Children's Health Insurance Program

Other insurance

If other insurance, please specify

How would you rate your health right now?

Excellent

Very good

Good

Fair

Poor

During the past 30 days, did you receive Inpatient Treatment in:

Hospital for Physical Complaint

Yes

No

If yes, how many nights?

Mental Health Facility?

Yes

No

If yes, how many nights?

Substance Use Disorder Facility?

Yes

No

If yes, how many nights?

During the past 30 days, did you receive Outpatient Treatment for:

Physical Complaint

Yes

No

If yes, how many times?

Mental Health Issues

Yes

No

If yes, how many times?

Alcohol or Substance Abuse

Yes

No

If yes, how many times?

During the past 30 days, did you receive Emergency Room Treatment for

Physical Complaint

Yes

No

If yes, how many times?

Mental Health Issues

Yes

No

If yes, how many times?

Alcohol or Substance Abuse

Yes

No

If yes, how many times?

Substance Abuse

In the past 30 days, how many days did you use the following?

Any Alcohol

Alcohol to Intoxication

Illegal Drugs

Prescription Drugs - not as prescribed

Mental Health

In the past 30 days, how many days did you experience the following?

Serious Depression

Anxiety or Tension

Trouble Understanding, Concentrating, or remembering

Trouble controlling violent behavior

Taken prescribed medication for mental health issues

Mental Health Service

In the past 30 days, how many time shave you met with the following people in order to address mental health issues in your life?

Psychiatrist

Psychologist, Mental Health Therapist/Counselor, or Social Worker

Mental Health Peer Specialist

In the past 30 days, how many times have you attended a support group for mental health recovery?

Last date individual participated in services? (if exact date is unknown, enter estimated date)

MM slash DD slash YYYY

Do you have a valid photo ID?

Yes

No

Address
5204 S. Colony Blvd #200
The Colony, TX 75056
(Located inside Hope Community Fellowship Church)

Business Hours
Tue – Thur …… 10 am – 2 pm
Case management by appointment

Phone
(972) 445-7770

Email
pam@nextstepstc.org

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