ConnectEd Contract

Company

Participant (Child's) General Information

Legal Last Name

Same as legal name

Program

Date of Birth

I currently live with: (If applicable: check all that apply) (Hold CTRL + left mouse click to select multiple options)

Live with other specify

Home Phone

Cell Phone

Social Media Name (This will only be used to reach out to you if we lose contact.)

Facebook Username

Instagram Username

What is your primary mode of transportation?

Other Transportation Specify

Have you ever been in state foster care?

If Yes, what age were you when you entered Foster Care?

If Yes, how long were you in Foster Care?

Legal First Name

Preferred Name

Age

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

Mailing Country

Type of Residence

If applicable, provide name of Shelter or Group Home

Home Phone - May we leave a message?

Cell Phone - May we leave a message?

Preferred Language

Other Language Specify

Emergency Contact

Emergency Contact Name

Emergency Contact Cell Phone

Emergency Contact Relationship

Emergency Contact Work/Home Phone

Participant Demographic / Gender Information

What sex were you assigned at birth?

Additional sex assigned at birth please specify

What pronouns do you use?

Additional pronouns please specify

Race/Ethnicity

Race/Ethnicity Other please specify

What religious group do you identify with the most? (Check all that apply) (Hold CTRL + left mouse click to select multiple options)

If other religious group, please specify

What is your current gender identity?

Additional Gender Identity please specify

What is your sexual orientation?

Additional sexual orientation please specify

Do you have any children?

If yes, please list age(s) of children

What is your current relationship status?

Additional relationship status please specify

What are your spiritual beliefs?

Participant Ethnic / Cultural Orientation

Did your family practice traditions and rituals associated with past family history?

If yes, what traditions and rituals?

If yes, was there a sense of pride in participating in those traditions and rituals?

Are there any cultral practices linked to your racial/ethnic background that are important to you?

If yes, please explain

SNAP - Strengths, Needs, Abilities and Preferences (Check all that apply) (Hold CTRL + left mouse click to select multiple options)

What are some strengths in your life?

Other strengths please specify

What do you need help with?

Other needs please specify

What skills are you good at?

Other abilities please specify

Preferences

Appointment Day / Time (specify) *We do our best to accommodate all preferences, however, limited staff or availability may prevent us from meeting all requests.

Presenting Concern / Goal

In your own words, briefly describe the problem or concern that brings you in today?

What do you hope to achieve by participating in this program?

Participant Medical/Mental Health Information

Are you currently receiving any behavioral health services from any other provider (i.e. psychiatrist, psychologist, therapist, counselor)?

If yes, provide additional information below (i.e. provider name, location and type of support that you are receiving)

Have you received behavioral health services in the past?

If yes, provide additional information below including where, dates of service, reason for services and outcome of services.

If you have been diagnosed by a Licensed Health Professional, please list any mental health diagnosis below.

Have you ever been hospitalized for any psychiatric/mental health reasons?

If yes, when was your most recent hospitalization, and how long were you there?

Have you ever attempted suicide?

If yes, when?

Are you currently contemplating suicide? *If yes, you are NOT alone! Call the National Suicide Prevention Lifeline for immediate support: 1-800-273-8255. Please be sure to share this with your provider at the start of the intake session.

Trauma History and Safety

Any history of abuse/trauma?

If yes, please check all that apply (Hold CTRL + left mouse click to select multiple options)

Other trauma specify

Do you have any current concerns for your safety? *If "yes" call 911 for any immediate concerns. Please be sure to share this with the provider at the start of the intake session.

If yes, please explain below.

How often does anyone, including family or a romantic partner, physically hurt you?

How often does anyone, including family or a romantic partner, insult or talk down to you?

How often does anyone, including family or a romantic partner, threaten you with harm?

How often does anyone, including family or a romantic partner, scream or curse at you?

Participant Personal Information

Employment/Income

Employment

Employer

Occupation

Length of employment

Hourly/Salary wage

Do you receive SSI?

Participant Education

Highest Grade/Certificate/Degree completed

If applicable, current school/university you are attending:

How would you rate your performance in school?

Do you have any problems in school?

If "yes", please explain

How do you learn best?

History of Arrest(s)

Have you ever been arrested?

If "yes", provide additional information (i.e. dates, charges, outcomes)

Currently on probation/parole?

Other Agencies

Are there any other agencies involved with you or your family (i.e., Child Protective Services, Adult Protective Services, Probation/Parole Officials)?

If yes, provide additional information below (i.e., agencies, contacts)

Substance Use History

How often do you use alcohol?

Alcohol estimated timeframe of use

How often do you use Nicotine (Cigarettes)?

Nicotine (Cigarettes) estimated timeframe of use

How often do you use Marijuana?

Marijuana estimated timeframe of use

How often do you use Cocaine?

Cocaine estimated timeframe of use

How often do you use Opiates?

Opiates estimated timeframe of use

How often do you use Sedatives?

Sedatives estimated timeframe of use

How often do you use Hallucinogens?

Hallucinogens estimated timeframe of use

How often do you use Stimulants?

Stimulants estimated timeframe of use

How often do you use Methamphetamines?

Methamphetamines estimated timeframe of use

Thoughts about making changes to substance use

Rating Scales

Directions: Each question refers to a possible area of our life, check the box next to the number you would use to describe how you feel this area of your life is going.

How well you are doing on your job:

How well you are doing in your marital/significant other relationship:

How well you are doing in your family relationships:

How well you are doing in relationships with people outside of your family:

Please rate your current physical health:

Please rate your general happiness and well-being:

Participant Name

Participant Signature

Date

Participant Needs Assessment

Directions: Check all the boxes that describe a possible area in your life that you may be concerned about.

Medical Needs and Mental Health (Do you have concerns about your health right now? Are you currently experiencing any symptoms or disabilities? Do you have any illnesses? Has it been more than 6 months since you have seen a medical provider? Are you able to make and get to your appointments easily? Do you need any help getting your prescriptions filled and taking your medications?

Income and Benefits (Are you in need of a steady source of income right now? Does your income not meet your basic expenses? Any serious outstanding bills? Do you need any help applying for or keeping your benefits?)

Food/Clothing (How is your diet lately? Do you have a regular source of healthy food? Are you maintaining your weight? Do you need help obtaining groceries or meals? Do you have enough clothing to keep you comfortable and protected? Can you get transportation from your home to the grocery store, easily?)

I need help with food today

I am interested in more information about TANF

I am interested in more information about SNAP

I am interested in more information about MEDICAID

Education (Do you need help getting back into school? Do you need help figuring out how to pay for school? Applying for loans, grants, scholarships? Do you need to get your GED? Are you in school and need help figuring out how to register/set educational goals? How to advocate for yourself with teachers?)

Family History and Relationships Are you having any problems with your current or past relationship(s)? Do you ever feel unsafe in your current living situation? Do you ever feel you or a family member/partner would resort to force when interacting? In the past have you ever been involved in a violent relationship?)

Substance Use (Have you used drugs or alcohol in the past? Are you currently using? If so, are you considering enrolling in treatment? Do you consider yourself in recovery and would like additional support? If currently using, are you in need of harm reduction methods? Do you need a referral for substance use treatment, a harm reduction program, or other support?)

Goal Setting/Self Care (Do you need help setting life goals? Figuring out how to care for yourself and live the life you want? Determining what you want in the future and steps to take in the present? Determining how to start new hobbies or meeting new people?)

Criminal Justice Process/Victim Rights (Are you a victim of a crime and need to know your rights, how to obtain notifications? Need a better understanding of the criminal justice process? Advocacy or accompaniment to law enforcement interviews?)

Incarceration (Are you on parole or probation? Serving any type of sentence currently [i.e., community service hours]? Any outstanding warrants, summonses, cases pending?)

Basic Sex Education/Harm Reduction (Do you have questions about safe sex practices and/or sexually transmitted diseases? Do you need information about how to keep yourself healthy? What works for you and what doesn’t when it comes to safer sex? Do want to work with someone to help you learn techniques to reduce the risk of transmitting a virus to others or getting exposed to infections?)

Contact Information