Keeping Our Neighborhoods Safe AssessmentName:________________________________________________ Alias:_____________________________________

Address:_____________________________________________________________________________________________

Date of Birth:_________ Age:___ Contact number:__________________(h)_________________________(c)

Family

Who are the significant people in your life? _____________________________ _________________________________

_____________________________ ________________________________ _________________________________

Natural/Step mother’s name _____________________________________ Living or Deceased? _______

Natural/Step father’s name ______________________________________ Living or Deceased? _______

Children (names and ages):______________________________________________________________________________

Is parenting difficult for you? Y/N

Who lives in your household? (names and relationship to you)

______________________________________________ ________________________________________________

______________________________________________ ________________________________________________

______________________________________________ ________________________________________________

Goal(s):_____________________________________________________________________________________________

Educational Information

Are you currently in an educational program? Y/N Describe _______________________________________________

Last grade attended __________ School/s attended _____________________________________________________

Average grades received _________ Did you like or dislike school?___________________

Favorite subject ____________________________ Least favorite subject _____________________________________

Difficulties associated with school ________________________________________________________________________

____________________________________________________________________________________________________

Goal(s): _____________________________________________________________________________________________

Employment history

Are you currently employed? Y/N Full-time [ ] Part-time [ ] How long have you worked there?______________

Company name:________________________________________ Do you have a valid driver’s license? Y/N

Do you have a Social Security Card? Y/N Do you have reliable transportation? Y/N

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How long have you been unemployed? _____________________________

Have you ever been in the military? Y/N Rank/When ___________________________________________________

What type of work have you done in the past?_______________________________________________________________

What type of work do you like to do?______________________________________________________________________

Do you have any trades or special skills?___________________________________________________________________

What do you think your strengths are?_____________________________________________________________________

Goal(s): ____________________________________________________________________________________________

___________________________________________________________________________________________________

Financial Status

Able to meet basic needs? Y/N Difficulties: ______________________________________________________________

Leisure activities

Favorite things to do? __________________________________________________________________________________

Difficulties: __________________________________________________________________________________________

Goal(s): _____________________________________________________________________________________________

Religion

Religion _______________________ Describe the role of religion/spirituality in your life: _________________________

____________________________________________________________________________________________________

Domestic Violence

Cite incidents: ________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Criminal History

Date: __________ Arrests: __________ Outcome: ____________________________________________________

Date: __________ Arrests: __________ Outcome: ____________________________________________________

Date: __________ Arrests: __________ Outcome: ____________________________________________________

Date: __________ Arrests: __________ Outcome: ____________________________________________________

Date: __________ Arrests: __________ Outcome: ___________________________________________________

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Substance Abuse

List all drugs you have used. _____________________________ _________________________________________

___________________________ _____________________________ ___________________________________

___________________________ _____________________________ ___________________________________

Do you think you have a substance abuse problem? Y/N

Alcohol: First Last Frequency __________ First Last Frequency

__________ First Last Frequency __________ First Last Frequency

__________ First Last Frequency __________ First Last Frequency

Have you ever been treated for substance abuse? Y/N When/Where?__________________________________________

Is there a history of substance abuse in your family? Y/N Describe ________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Are there members or friends who say you have a substance abuse problem? Y/N

What are the problems associated with chemical dependency? (DUI, accidents, legal, suspensions, etc.)

Health

Any past medical problems?_____________________________________________________________________________

Status of general health _________________________________ Where do they get health care services?______________

Date of last physical? _____________ Any current physical complaints? ________________________________________

Hospitalizations (when/why/where) _______________________________________________________________________ ____________________________________________________________________________________________________

Current difficulties? ____________________________________________________________________________________

Goal(s): _____________________________________________________________________________________________

Mental Health

Is there a history of mental illness in your family?____________________________________________________________

Have you ever been treated for a mental illness? Y/N What/Where?___________________________________________

Treatment services (counseling, prescriptions, etc.) ___________________________________________________________

What do you see as problems in your life? __________________________________________________________________

How bad do you think they are? __________________________________________________________________________

Strengths? ___________________________________________________________________________________________

Weaknesses? _________________________________________________________________________________________

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