Submit your Intake AssessmentThis survey is submitted during your intake. Complete questions and then click submit - it will be sent to your case manager. Date of Intake * MM DD YYYY Head of Household * First Name Last Name Phone * If you do not have a phone, please enter all zeros. (###) ### #### Employer Supervisor's Name Supervisor's Phone Number (###) ### #### Spouse First Name Last Name Spouse Phone * If you do not have a phone, please enter all zeros. (###) ### #### Spouse Employer Spouse's Supervisor's Name Spouse's Supervisor's Phone (###) ### #### Please provide information about your children. If you do not have children, please skip to next section. Child's Name First Name Last Name Custody Information Please select the option closest to your situation. This child will reside with my full-time at Hope Harbor This child will visit me and stay overnight on occasion This child will do supervised visits with me at the shelter I do not currently have custody or visits with this child Child's Date of Birth MM DD YYYY Child's School Child's Name First Name Last Name Custody Information Please select the option closest to your situation. This child will reside with my full-time at Hope Harbor This child will visit me and stay overnight on occasion This child will do supervised visits with me at the shelter I do not currently have custody or visits with this child Child's Date of Birth MM DD YYYY Child's School Child's Name First Name Last Name Custody Information Please select the option closest to your situation This child will reside with my full-time at Hope Harbor This child will visit me and stay overnight on occasion This child will do supervised visits with me at the shelter I do not currently have custody or visits with this child Child's Date of Birth MM DD YYYY Child's School Child's Name First Name Last Name Custody Information Please select the option closest to your situation This child will reside with my full-time at Hope Harbor This child will visit me and stay overnight on occasion This child will do supervised visits with me at the shelter I do not currently have custody or visits with this child Child's Date of Birth MM DD YYYY Child's School Child's Name First Name Last Name Custody Information Please select the option closest to your situation This child will reside with my full-time at Hope Harbor This child will visit me and stay overnight on occasion This child will do supervised visits with me at the shelter I do not currently have custody or visits with this child Child's Date of Birth MM DD YYYY Child's School IN CASE OF EMERGENCY, HOPE HARBOR SHOULD CONTACT: Name * First Name Last Name Phone: * Relationship: * Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country MEDICAL INFORMATION Family Member Name: Physician's Information: Medication Name, Dosage, Prescribing Physician, Reasons for taking: Any allergies? (food, medication, etc) Medical Information: Family Member Name: Physician's Information Medication Name, Dosage, Prescribing Physician, Reasons for taking: Any allergies? (food, medication, etc) Family Member Name Physician's Information: Medication Name, Dosage, Prescribing Physician, Reasons for taking: Any allergies? (food, medication, etc) Does anyone in your family have dietary restrictions? Please list any specific or potential nutritional needs or dietary restrictions, including significant health issues that could be impacted by diet such as diabetes. Does anyone in your family carry an epi pen? If so, who? Is your family current on all regularly scheduled exams? If No, please list family member and needed exam (including well child checks, vision screening, dental exams, immunizations, physicals, or reproductive health exams) What major medical concenrs are you (or anyone in your family) experiencing? (pregnancy, cancer, seizures, etc) Do you, or anyone in your family have a mental health diagnosis? If Yes, who? Do you have supporting documentation? Do you have a guardian/payee? If Yes, please list their contact info below. Do you or anyone in your family have problems with medication, alcohol, or other drugs? If YES please explain: Has anyone in your household been to treatment? If YES who and when? When using, what are your drug(s) of choice? How old were you when you first started drinking/using? When did you start drinking/using on a regular basis? Have you been in inpatient treatment? If yes how many times? Are you or anyone in the family currently involved with any drug and alcohol counseling? If yes, what is the name of your counselor? Do you have a sponsor? Do you currently attend AA/NA? Who are your major supporters in your recovery? HOUSING INFORMATION Address 1 Please list your 5 most recent addresses below Address 1 Address 2 City State/Province Zip/Postal Code Country Start MM DD YYYY End MM DD YYYY Reason for Leaving Amount Owed to Landlord, if any. $ Address 2 Address 1 Address 2 City State/Province Zip/Postal Code Country Start MM DD YYYY End MM DD YYYY Reason for Leaving Amount Owed to Landlord, if any. $ Address 3 Address 1 Address 2 City State/Province Zip/Postal Code Country Start MM DD YYYY End MM DD YYYY Reason for Leaving Amount Owed to Landlord, if any. $ Address 4 Address 1 Address 2 City State/Province Zip/Postal Code Country Start MM DD YYYY End MM DD YYYY Reason for leaving Amount Owed to Landlord, if any. $ Address 5 Address 1 Address 2 City State/Province Zip/Postal Code Country Start MM DD YYYY End MM DD YYYY Reason for Leaving Amount Owed to Landlord, if any. $ Have you received housing assistance? (Section 8, Public Housing, Supportive Housing, Goodwill, or Region 3) If YES when and where? Have you received deposit/rental assistance through a community agency? (churches, DHHS, or CNCAP) If YES when and how much? Have you received energy assistance for DHHS? If YES when and how much? What are barriers to obtaining/maintaining housing? (criminal history, credit, rental history, past due utilities, affordable housing) What are your housing goals? EDUCATION Do you have plans to continue your education? If YES please explain What diplomas, degrees, certifications, or training have your received? IF APPLICABLE - Are your children in need of basic school supplies? If YES what items are needed? IF APPLICABLE - Are your children involved in any school sports? If YES who and which sports? IF APPLICABLE - Describe your involvement with your child’s school. IF APPLICABLE - Do your children have a current Individual Education Plan (IEP)? If YES who? FAMILY & RELATIONSHIPS Who do you rely on for support or could call if you were having a bad day? How often are you able to contact this person? What friends and family do you have in the area? What is your relationship status? If applicable, Name of significant other? EMPLOYMENT Current or Most Recent Employer Start MM DD YYYY End MM DD YYYY Reason for Leaving Prior Employer Start MM DD YYYY End MM DD YYYY Reason for Leaving Prior Employer Start MM DD YYYY End MM DD YYYY Reason for Leaving Employment Goals What type of work interests you? What barriers are preventing you from accessing or maintaining employment? (reliable transportation, criminal background, disability, etc) Are you currently receiving / participating in employment services? (Vocational Rehabilitation, Goodwill Services, Nebraska Workforce Development, ResCare, or Employment Agencies) If YES please list contact information. LEGAL Are you currently involved in the legal system? (probation, parole, drug court, pending/active charges, child support, child custody, divorce)...If YES please explain and list contact information: Have you been convicted of any other than a minor traffic violation (speeding ticket, etc.)? YES/NO if YES please list information below: INCOME / BUDGET Source of Income: Amount per month: $ Source of Income: Amount per month: $ Source of Income: Amount per month: Do you have debt? If so, what do you currently owe? TRANSPORTATION Do you have a driver's license? Yes No What is the make, model, and year of your vehicle (if applicable)? How much is your car payment? $ Where do you receive car insurance through? How much do you pay for car insurance? If you do not have a vehicle, what method of transportation do you use? By entering your initials below, you are agreeing to take full responsibility for all medications, allergy related needs, and medical care. Additionally, you are giving Hope Harbor permission to contact your emergency contacts and employer. This contact would include open written and verbal communication for all family members expiring in 1 year from date of signature. * Thank you!
