1. Keeping Our Neighborhoods Safe Assessment Name:________________________________________________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/NDescribe _______________________________________________ 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/NFull-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 How long have you been unemployed? _____________________________ Have you ever been in the military? Y/NRank/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: ___________________________________________________ Substance Abuse List all drugs you have used. ______________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Do you think you have a substance abuse problem? Y/N Alcohol:FirstLast Frequency __________FirstLast Frequency __________FirstLast Frequency__________FirstLast Frequency __________FirstLast Frequency__________FirstLast Frequency Have you ever been treated for substance abuse? Y/NWhen/Where?__________________________________________ Is there a history of substance abuse in your family? Y/NDescribe ________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 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/NWhat/Where?___________________________________________ Treatment services (counseling, prescriptions, etc.) ___________________________________________________________ What do you see as problems in your life? __________________________________________________________________ How bad do you think they are? __________________________________________________________________________ Strengths? ___________________________________________________________________________________________ Weaknesses? _________________________________________________________________________________________