Intake Form

INTAKE SHEET

Date: Client Code #: ASA NASA Other

Referral Source: Phone #: Fax:

Client’s Name

Address: Zip

Telephone: Home Work Cell:

DOB Age SSN Race

Employer Occupation:

Address: Zip Telephone

Education Level Marital Status: SLTMSEPDIVW

Name of Victim (Spouse/Partner)

Nature of Relationship: LTMSEPDIV

Address: Zip

Telephone: Home Cell Work

Occupation: DOB Race

Client waives his/her right under the confidentiality law to allow Agency to contact the victim listed above and client affirms that the information provided about the victim is correct to the best of his/her knowledge

Initial:

Intake Application Form

Children Born To This Relationship

PRESENT PARTNER
Name of present Partner if different from the Victim

Address

Nature of Relationship: Circle response: MarriedLTSEPDIV

Home Phone: Cell: Work Phone:

Do you have children with your present partner yesno

If yes, how many children

I authorize staff of Sunbless Healthcare Services to contact my present partner to verify past history of abuse and or offer our services. Please Initial:

Income Information:

Gross Monthly Income Verification

Income Source: Salary/WagesPensionSocial SecurityDIVSSIOther DisabilityUnemploymentOther

We are required to obtain some personal information from you for the purpose of this assessment. You affirm that the information you will provide is true to the best of your Knowledge. You understand that if any of the information provided during the intake is found to be false, you may be terminated from the program and sent back to the agency that referred you. Initial:

Intake Application Form

Alcohol Abuse

1. Do you use alcohol? yesno

2. If yes, how often do use alcohol? DailyWeeklyWeekendsat OccasionsOther

3. What Quantity of alcohol do you use alcohol

4. Have you ever received any professional help in the past? yesno

5. Contact Person Phone Number

6. Are you a member of any Local AA? yesno
   If yes, can you verify your membership? yesno
   If no, Explain

7. For how long have you been using alcohol?

Drug Abuse

1. Do you use illicit drugs yesno

2. If yes, what are your drugs of choice?

3. How often do you use drugs? DailyWeeklyWeekendsat OccasionsOther

4. What quantity of drugs do you use at a time?

5. How long have you been using drugs?

6. Have you ever received any Professional help for drug abuse in the past? yesno Where

7. Contact Person Position Phone

8. Are you a member of any Local NA? yesno
   If yes, can you verify your membership? yesno
   If no, Explain

9. Do you understand that you are required to complete a drug/alcohol testing within 24 hrs of completing intake? yesno The Intake Staff will schedule a test immediately.

Psychiatric/Psychological

1. Have ever received mental health counseling or been hospitalized for Psychiatric Psychotherapy? yesno

2. If yes, Where

3. What is the name of Your Doctor(s)?

4. What was the nature of the problem?

5. What was the Treatment?

6. Did you take prescription drugs? yesno
   If yes, explain

7. Are you currently in psychiatric treatment? yesno
   Where

8. Are you currently taking prescribed medication? yesno What type

9. Do you have any thoughts of killing or hurting yourself or orders? yesno. If yes Could you explain?

10. You see things others cannot see? yesno; hear voices others cannot hear? yesno

11. If any of the above response is yes, could you explain?

Domestic Violence History

1. How many adult relationships have you had in the past?

2. How many of your past relationships resulted in abuse or Physical Violence?

3. How many times did the Police intervene in your relationships?

4. Have you ever been in a domestic violence or anger management program in the past? yesno If yes, Where what year?

5. Where you compliant with the treatment program? yesno

6. If not compliant, Why?

7. Are you currently ordered by the courts not to make contacts with your partner? yesno if yes, how long will the “no contact” order last?

8. Are you in compliant with the “no contact” order? yesno

Criminal History

1. Have you been convicted of any criminal offense before? yesno

2. If you have been convicted of a criminal offense in the past, could you explain in details the nature of the offense?

3. Did you serve time in prison for the conviction(s)? yesno

4. If yes, how long was the prison/jail term?

Client authorizes Sunbless Healthcare Services to obtain criminal background information from the criminal justice system and or including other agencies or persons who might possess such information:
Initial:

Possession/Ownership of Weapons

1. Do you currently own any weapon(s)? yesno

2. How many weapons do you currently own?

3. What types of weapon do you currently own?

4. If you own any gun(s), are they licensed? yesno

5. If the guns are not licensed, why?

6. Have you used or threatened to use any of the weapon(s) in the past against current or previous partner in a conflict? yesno

7. Are you currently restricted by law from owning a gun? yesno

Child Support

1. Are currently ordered by the court to pay child support or family maintenance? yesno

2. If yes, how much do you pay per month? $

3. Who do you make payments to?

4. Are you currently up to date in child support payments? yesno

5. If not up to date, why

Incident Report

6. Briefly state in your own words what happened

The information I have provided in this application is true. I understand that I could be terminated from the program if any of the information is found to be misleading.

Client Name Signature Date

Anger Management Program

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Sunbless Healthcare Services staff to release/receive information about my

1. Status/Progress

2. Successful Completion

3. Unsuccessful Termination

4. Other Service Referral

To/from Mr./Ms.

of (Agency or Department)

I understand that this authorization shall be in effect for the duration of my enrollment in this agency’s program. I also understand that I may revoke this consent at any time in writing except to the extent that action has been taken in reliance there off.

Client Name

Client Signature Date:

AIP Staff Signature Date

ABUSER INTERVENTION PROGRAM (AIP)

AUTHORIZATION TO CONTACT THE VICTIM

I, Mr./Ms.

Hereby authorize the Mr./Ms.
Staff of Sunbless Healthcare Services to contact and communicate with the victim Mr./Ms. concerning my referral.

I understand that the purpose of this contact shall be to offer Sunbless Healthcare Services to the victim and to advise victim of client’s compliant or non-compliant status in the AIP Program.

I understand that this waiver of confidentiality right will remain valid for the period of my treatment in this program.

I also understand that this authorization can be revoked at any time in writing except to the extent that action has been taken in reliance thereof.

Client Name

Signature Date

AIP Staff Signature: Date

PAROLE AND PROBATION PROFILE FORM

1. Client’s Name:

2. Address: zip:

3. Home Phone Number: Work Phone:

4. Are currently on parole/probation: yesno

5. If yes, what is the duration of your parole/probation

6. State the date parole/probation will end

7. Is this the first time on parole/probation yesno

8. If no, can you explain?

9. Who is your current parole/probation Agent:

Name:
Office Address/Location:
Phone Number: Ext.: Cell
How often are you scheduled to visit
Day(s) Time:

AUTHORIZATION TO CONTACT PRESENT PARTNER

I , authorize Mr. / Ms.

of Sunbless Healthcare Services to contact my present partner. The purpose of this contact is to verify history of abuse and violence in my present relationship and to offer their services.

I understand that I can revoke this authorization at any time except to the extent action has been taken there from. I also understand that this authorization shall remain in effect till the duration of my services at Isaiah Associates Inc unless revoked.

Client Name:

Client Signature:

Date:

Staff Signature:

Date: