HOMELESS VETERAN SERVICES

Integrated Program Screening & Assessment Package

The Homeless Veteran Service (HVS) is committed to providing social,
physical, spiritual psychological, and vocational-economical
rehabilitation to eligible homeless, or about to be homeless, veterans
throughout Alaska. Our mission, 'to end the cycle of homelessness', is
pursued through five programs: Outreach, Domiciliary in-patient,
Compensated Work Therapy (CWT), Transitional Residence (TR), Veterans
Industries (VI), and Housing and Urban Development-Veteran Affairs
Supported Housing (HUD-VASH).

Basic criteria eligibility for all programs is:

-   Eligible US veteran verified through the Alaska VA Health Care
    System.

-   Homeless or conditions that present immediate danger to loss of
    present housing.

-   Able to perform activities of daily living, ambulatory, and self
    monitor medications.

-   Voluntarily seeking admission and motivated to pursue independent
    living.

-   Willing to participate in a therapeutic program individualized to
    address substance abuse, mental health, and psychosocial and
    vocational issues.

-   No outstanding warrants or probation conditions that restrict access
    to a particular population (e.g., barred from being around
    children).

-   Not in need of medical detoxification or stabilization for an acute
    psychotic or suicidal episode.

-   Committed to long-term rehabilitation and community reentry.

Each program may have additional admission criteria specific to its
mission and goals.

A clinical decision, for appropriate placement, services, and referrals
the veteran may receive from Homeless Veteran Services, will be made at
the screening appointment. Screening appointments are on selected
Fridays, and start at 9:00 AM.

**Outreach:** The mission is to reach out to homeless veterans "where
they are", and to engage them in accessing services they need to achieve
stability and realize their potential. The program is based at the
Brother Francis Shelter and provides intensive community based case
management services.

**Domiciliary:** The mission is **"to end the cycle of homelessness";**
provide holistic treatment, designed to promote change through
membership in a community based therapeutic setting that cultivates
honesty, responsibility, recovery and the treatment of all persons with
compassion and respect. The program addresses the specific medical and
psychosocial needs of each homeless veteran, while empowering them to
develop a foundation of effective coping and problem solving skills
needed to transition into community based living. Average length of stay
ranges from 90 -- 180 days.

**Compensated Work Therapy/Transitional Residence (CWT/TR):** The
mission is **"to end the cycle of homelessness".** This program's goal
is to provide a semi-structured temporary home environment for veterans
to apply learned skills and begin the transition to independent living.
This goal is accomplished through a combination of work therapy and
intensive case management. Veterans are required to work in the CWT
program, have a budget & savings plan, purchase groceries, prepare
meals, use public transportation, develop therapeutic plans for
maintained recovery and psychiatric stability, develop financial and
vocational goals for future self-sufficiency. Maximum length of stay is
one year. Criteria specific to this program include:

-   Completion of treatment/residential program or documented sobriety
    and/or documented compliance with psychiatric treatment including
    medication.

-   Established goal of obtaining independent housing and work or
    meaningful community participation.

-   Willing and able to participate in the CWT Transitional Work
    Program.

-   Physically able to live independently, and possess the cognitive
    ability, to function independently with minimal supervision.

-   Develops and adheres to a plan that addresses personal recovery,
    mental health, medical, financial, and vocational issues.

**Veterans Industries (VI):** The mission is **"to end the cycle of
homelessness".** This program's goal is to provide rehabilitation in the
area of work restoration. The objective is to assist veterans in
developing work tolerance, good working habits, and skills for
successful community re-entry. VI also offers supportive employment at
actual industry and service locations in the community. This provides
veterans the opportunity to develop employment references, appropriate
work habits, and funds for community re-entry and achieving their
vocational goals. Maximum program length is one year. Criteria specific
to this program includes:

-   Unemployed

-   Income below \$1200 monthly

**Housing & Urban Development/ Veterans Affairs Supported Housing
(HUD-VASH):** The mission is **"to end the cycle of homelessness".** To
assist the veteran to achieve this mission, the program's goal is to
provide affordable independent housing and supportive case management
services to solidify independent, functional, and meaningful community
living. The program assists formerly homeless veterans with finding and
maintaining permanent housing in the Anchorage community. Criteria
specific to this program includes:

-   Veterans must have a regular source of income, and ample savings to
    cover costs associated with obtaining housing (e.g., security
    deposit, groceries, cleaning supplies and living necessities).

-   Exhibited track record of recovery and/or mental health stability.
    (Minimum of 3 months)

-   Eligible to participate with HUD and meet HUD eligibility standards.

-   Available for single participant occupancy only. (Special
    circumstances discussed)

-   Commit to a minimum of 20 hours per week of productive activity
    (employment, training, education, or volunteer work).

**To be screened for a program:**

1.  Complete and submit the attached HVS Integrated Screening and
    Assessment Form. The completed form may be submitted by:

    -   Fax: Attention: Carol Pfeifer @ 272-4666 or 273-4085

    -   Mail: HVS Domiciliary

> Attention: **Carol Pfeifer**
>
> 3001 'C' Street
>
> Anchorage, AK 99503

-   Completed form may also be dropped off at the Domiciliary front
    desk.

2.  Complete the contact information so that you can be informed of your
    screening appointment.

3.  To inquire about the status of a screening appointment or to cancel
    or reschedule an existing appointment, contact **Carol Pfeifer @
    277-1731**.

4.  Screenings occur on selected Friday's beginning at 9 AM. All
    veterans to be screened are to show at 9 AM.

5.  No shows for screening appointments will be required to resubmit
    their screening forms unless they reschedule prior to their initial
    appointment.

6.  The screening team consists of 3-5 clinicians from different HVS
    programs.

7.  Placement decisions may include recommendations for a more
    appropriate level of care within HVS.

8.  Every attempt is made to accommodate the veteran's 'presenting
    problem'.

9.  Clinical and therapeutic factors will be evaluated to determine what
    level of care provides a veteran the best opportunity for success.

**Homeless Veteran Services**

**Integrated Screening and Assessment Form**

# VETERAN DESCRIPTION

**NAME: Age:**

**SSN: Date of Birth:**

**Birthplace: Sex:** **Male** **Female**

**Contact Phone #: [( ) ]{.underline}**

**Ethnicity (check only one)**

**Hispanic, White** **Black, not Hispanic** **Pacific Islander**

**Hispanic, Black** **Asian** **Other**

**American Indian or Alaskan** **White, not Hispanic**

**What is your current marital status? (Check only one)**

**Married** **Widowed** **Divorced**

**Remarried** **Separated** **Never Married**

# [Military History]{.smallcaps}

**Air Force** **Army** **Marines** **Navy** **Coast Guard**

**National Guard**

Period of Service (check longest one)

**Pre -- WW II (11/18-11/41)** **Between Korean & Vietnam Eras
(2/55-7/64)**

**WW II (12/41-12/46)** **Korean War (7/50-1/55)**

**Vietnam Era (8/64-4/75)** **Post-Vietnam (5/75-7/90)**

**Persian Gulf (8/90-8/91)** **Post Persian Gulf**

**Did you ever receive hostile or friendly fire in a combat zone?**

**Yes** **No**

# [Living Situation]{.smallcaps}

**Where did you sleep last night? (check only one)**

**Own apartment, room, or house** **Shelter/Temporary Housing Program**

**Apartment, room, or house of family member/friend** **Prison or Jail**

**Institution (hospital, Detox)** **No residence (outdoors, car,
truck)**

**How long have you been homeless?**

**Not currently homeless** **At least 1 year but less than 2 years**

**At least 1 night but less than 1 month** **Two years or more**

**At least 1 month but less than 6 months** **Unknown**

**At least 6 months but less than 1 year**

**During the past 30 days (1 month), how many days did you sleep in the
following places?**

**(Note: Estimates may often be necessary here. In such cases, make sure
the \# of days adds up to 30.)**

a.  **Own apartment, room, or house**

b.  **Someone else's apartment, room, or house**

c.  **Hospital or nursing home (including Detox centers)**

d.  **Domiciliary**

e.  **VA contracted halfway programs (Genesis or Clithroe)**

f.  **Non-halfway house program**

g.  **Hotel, Single Room Occupancy (SRO), boarding home**

h.  **Shelter for the homeless (including sleep-off centers)**

i.  **Outdoors (sidewalk, park, abandoned building)**

j.  **Automobile, truck, boat**

k.  **Prison, jail**

# [Medical]{.smallcaps}

**Do you feel you have any serious medical problems?**

**Yes** **No**

**Do you have any of the following medical problems?**

**Oral/dental problems** **Yes** **No**

**Eye problems (other than glasses)** **Yes** **No**

**Hypertension** **Yes** **No**

**Heart or cardiovascular problems** **Yes** **No**

**COPD/emphysema** **Yes** **No**

**TB** **Yes** **No**

**Gastrointestinal problems** **Yes** **No**

**Liver disease** **Yes** **No**

**Seizure disorder** **Yes** **No**

**Orthopedic problems** **Yes** **No**

**Significant skin problems** **Yes** **No**

**Significant trauma (blows to head)** **Yes** **No**

**Other (specify)** **Yes** **No**

## [Substance Abuse]{.smallcaps}

**Do you have a problem with alcohol dependency now?** **Yes** **No**

**Have you had a problem with alcohol dependency in the past?** **Yes**
**No**

**Have you ever been hospitalized for treatment of alcoholism?** **Yes**
**No**

**During the past 30 days, how many days would you say that you used
alcohol at all?**

**During the past 30 days, how many days did you drink to
intoxication?**

**Do you have a problem with drug dependency now?** **Yes** **No**

**Have you had a problem with drug dependency in the past?** **Yes**
**No**

**Have you ever been in a residential treatment program or hospitalized
for treatment of alcoholism?**

> **Yes** **No**

**During the past 30 days, how many days would you say that you used any
drugs, such as heroin or methadone; barbiturates (downers); cocaine or
crack; amphetamines (speed or uppers); hallucinogens (acid); or
inhalants (glue, nitrous oxide, gas) at all?**

**During the past 30 days. How many days did you use more than one kind
of drug?**

## [Psychiatric Status]{.smallcaps}

**Do you have any current psychiatric or emotional problem(s) other than
alcohol or drug use?**

> **Yes** **No**

**Have you ever been hospitalized for a psychiatric problem?** **Yes**
**No**

**Have you used the VA system for medical or psychiatric care in the
past six months?**

> **Yes** **No**

**Now, I'm going to ask you about some psychological or emotional
problems you might have had in the past 30 days. You can just say "yes"
or "no" for these. During the past 30 days, have you had a period (that
was not the direct result of alcohol or drug use) in which you... (Check
one answer for each item: blank responses will not be considered a "no"
response.**

a.  **Experienced a serious depression** **Yes** **No**

b.  **Experienced serious anxiety or tension** **Yes** **No**

c.  **Experienced hallucinations** **Yes** **No**

d.  **Experienced trouble understanding, concentrating or remembering**
    **Yes** **No**

e.  **Had trouble controlling violent behavior** **Yes** **No**

f.  **Had serious thoughts of suicide** **Yes** **No**

g.  **Attempted suicide** **Yes** **No**

h.  **Took prescribed medication for a psychological/emotional problem**
    **Yes** **No**

## [Employment Status]{.smallcaps}

**What is your usual employment pattern, the past three years? (check
only one)**

**Full time (40 hrs/wk)** **Full time (irregular)** **Part time (regular
hours)**

**Part time (irregular hours)** **Student** **Service**

**Retired/disability** **Unemployed**

**How many days did you work for pay in the past thirty days?**

***Do you receive any of the following kinds of public support?***

**Service Connected/Psychiatry** **Yes** **No**

**Service Connected/Other** **Yes** **No**

**Receive Non-Service Connected Pension** **Yes** **No**

**Non-VA disability (SSDI)** **Yes** **No**

**Other public support (including cash, APA, food stamps, Medicaid,
etc.)** **Yes** **No**

## [Medical History]{.smallcaps}

Care from another VA facility; please give dates, and locations of the
three most recent occurrences:

**1. Date: Location: Care received:**

2\. Date: Location: Care received:

3\. Date: Location: Care received:

Complete the following (Yes for current problem, Past if you have had a
problem, or No if never)

+---+---+---+---------------------+---+---+---+------------------------+
| * | # | * | **[Pro              | * | * | * | **[                    |
| * | # | * | blem]{.underline}** | * | * | * | Problem]{.underline}** |
| [ | # | [ |                     | [ | [ | [ |                        |
| Y |   | N |                     | Y | P | N |                        |
| e | P | o |                     | e | a | o |                        |
| s | a | ] |                     | s | s | ] |                        |
| ] | s | { |                     | ] | t | { |                        |
| { | t | . |                     | { | ] | . |                        |
| . |   | u |                     | . | { | u |                        |
| u |   | n |                     | u | . | n |                        |
| n |   | d |                     | n | u | d |                        |
| d |   | e |                     | d | n | e |                        |
| e |   | r |                     | e | d | r |                        |
| r |   | l |                     | r | e | l |                        |
| l |   | i |                     | l | r | i |                        |
| i |   | n |                     | i | l | n |                        |
| n |   | e |                     | n | i | e |                        |
| e |   | } |                     | e | n | } |                        |
| } |   | * |                     | } | e | * |                        |
| * |   | * |                     | * | } | * |                        |
| * |   |   |                     | * | * |   |                        |
|   |   |   |                     |   | * |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Headaches      |   |   |   | ##### Diffic           |
|   |   |   |                     |   |   |   | ulty with coordination |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ###                 |   |   |   | ##### Numbness         |
|   |   |   | # Difficulty seeing |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | ##### Limited movement |
|   |   |   |  Difficulty reading |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Do you wea     |   |   |   | ##### Musc             |
|   |   |   | r glasses/contacts? |   |   |   | le cramps or twitching |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | #####                  |
|   |   |   |  Difficulty hearing |   |   |   |  Tremors, hand shaking |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Do yo          |   |   |   | ##### N                |
|   |   |   | u use a hearing aid |   |   |   | eck/shoulder/back pain |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Frequent colds |   |   |   | ##### Joint pain       |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ###                 |   |   |   | ##### Do you use       |
|   |   |   | # Frequent earaches |   |   |   |  crutches/cane/walker? |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Dizziness      |   |   |   | ##### Do you wea       |
|   |   |   |                     |   |   |   | r a prosthetic device? |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #                   |   |   |   | ##### Skin problems    |
|   |   |   | ### Dental problems |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Di             |   |   |   | ##### Bruise easily    |
|   |   |   | fficulty swallowing |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### F              |   |   |   | #####                  |
|   |   |   | requent indigestion |   |   |   |  Sores that don't heal |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ##                  |   |   |   | ##### So               |
|   |   |   | ## Heartburn or gas |   |   |   | res, open wound(s) now |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | ##### Current injuries |
|   |   |   |  Nausea or retching |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | #####                  |
+---+---+---+---------------------+---+---+---+------------------------+
| * | # | * | **[Pro              | * | * | * | **[                    |
| * | # | * | blem]{.underline}** | * | * | * | Problem]{.underline}** |
| [ | # | [ |                     | [ | [ | [ |                        |
| Y |   | N |                     | Y | P | N |                        |
| e | P | o |                     | e | a | o |                        |
| s | a | ] |                     | s | s | ] |                        |
| ] | s | { |                     | ] | t | { |                        |
| { | t | . |                     | { | ] | . |                        |
| . |   | u |                     | . | { | u |                        |
| u |   | n |                     | u | . | n |                        |
| n |   | d |                     | n | u | d |                        |
| d |   | e |                     | d | n | e |                        |
| e |   | r |                     | e | d | r |                        |
| r |   | l |                     | r | e | l |                        |
| l |   | i |                     | l | r | i |                        |
| i |   | n |                     | i | l | n |                        |
| n |   | e |                     | n | i | e |                        |
| e |   | } |                     | e | n | } |                        |
| } |   | * |                     | } | e | * |                        |
| * |   | * |                     | * | } | * |                        |
| * |   |   |                     | * | * |   |                        |
|   |   |   |                     |   | * |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Constipation   |   |   |   | ##### Lice or crabs    |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Vomiting       |   |   |   | ##### Athlete's foot   |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Diarrhea       |   |   |   | ##### Rash             |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Hemorrhoids    |   |   |   | ##                     |
|   |   |   |                     |   |   |   | ### Frequent urination |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Abdomin        |   |   |   | ##### Bloody urine     |
|   |   |   | al pain or cramping |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ##                  |   |   |   | ####                   |
|   |   |   | ## Loss of appetite |   |   |   | # Burning on urination |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Do you ev      |   |   |   | #                      |
|   |   |   | er induce vomiting? |   |   |   | #### Unusual discharge |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | #####                  |
|   |   |   |  Recent weight gain |   |   |   | Up at night to urinate |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ###                 |   |   |   | #####                  |
|   |   |   | # Compulsive eating |   |   |   | Men: prostate problems |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Fear you c     |   |   |   | ##### Unde             |
|   |   |   | an't control eating |   |   |   | r care of psychiatrist |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | #####                  |
|   |   |   |  Recent weight loss |   |   |   | Prior psychiatric care |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Chest pain     |   |   |   | ##### His              |
|   |   |   |                     |   |   |   | tory of mental illness |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | ##### Wom              |
|   |   |   | Shortness of breath |   |   |   | en: menstrual problems |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Palpitations   |   |   |   | ###                    |
|   |   |   |                     |   |   |   | ## Women: age of 1^st^ |
|   |   |   |                     |   |   |   |  period \_\_\_\_\_\_\_ |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Do you smoke?  |   |   |   | ##### Women: PMS       |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | ##                     |
|   |   |   | High blood pressure |   |   |   | ### Women: date last p |
|   |   |   |                     |   |   |   | eriod \_\_\_\_\_\_\_\_ |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Ankle swelling |   |   |   | ##### Women: Last Pa   |
|   |   |   |                     |   |   |   | p smear \_\_\_\_\_\_\_ |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Cough          |   |   |   | #                      |
|   |   |   |                     |   |   |   | #### Use birth control |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Loss of sleep  |   |   |   | ##### Pregnant         |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | ####                |   |   |   | ##### Foot pain        |
|   |   |   | Weakness, tiredness |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| H |   |   |                     |   |   |   |                        |
| a |   |   |                     |   |   |   |                        |
| v |   |   |                     |   |   |   |                        |
| e |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| y |   |   |                     |   |   |   |                        |
| o |   |   |                     |   |   |   |                        |
| u |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| h |   |   |                     |   |   |   |                        |
| a |   |   |                     |   |   |   |                        |
| d |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| a |   |   |                     |   |   |   |                        |
| n |   |   |                     |   |   |   |                        |
| y |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| o |   |   |                     |   |   |   |                        |
| f |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| t |   |   |                     |   |   |   |                        |
| h |   |   |                     |   |   |   |                        |
| e |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| f |   |   |                     |   |   |   |                        |
| o |   |   |                     |   |   |   |                        |
| l |   |   |                     |   |   |   |                        |
| l |   |   |                     |   |   |   |                        |
| o |   |   |                     |   |   |   |                        |
| w |   |   |                     |   |   |   |                        |
| i |   |   |                     |   |   |   |                        |
| n |   |   |                     |   |   |   |                        |
| g |   |   |                     |   |   |   |                        |
| ? |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Measles        |   |   |   | #####                  |
|   |   |   |                     |   |   |   | Kidney problems/stones |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Mumps          |   |   |   | ##### Typhoid          |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Chicken pox    |   |   |   | ##### Herpes           |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Scarlet fever  |   |   |   | ##### Diabetes         |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Arthritis      |   |   |   | ##### Gonorrhea        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Po             |   |   |   | ##### German measles   |
|   |   |   | sitive TB skin test |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Cancer         |   |   |   | ##### Liver problems   |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Heart disease  |   |   |   | ##### Ulcers           |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #                   |   |   |   | ####                   |
|   |   |   | ### Rheumatic fever |   |   |   | # Tuberculosis vaccine |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Polio          |   |   |   | ##### Hepatitis        |
+---+---+---+---------------------+---+---+---+------------------------+
|   |   |   | #### Syphilis       |   |   |   | ##### Stroke           |
+---+---+---+---------------------+---+---+---+------------------------+
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
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+---+---+---+---------------------+---+---+---+------------------------+
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+---+---+---+---------------------+---+---+---+------------------------+
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|   |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
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| - |   |   |                     |   |   |   |                        |
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| : |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
| # |   |   |                     |   |   |   |                        |
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| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
| # |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
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| l |   |   |                     |   |   |   |                        |
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| a |   |   |                     |   |   |   |                        |
| s |   |   |                     |   |   |   |                        |
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| s |   |   |                     |   |   |   |                        |
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| y |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| a |   |   |                     |   |   |   |                        |
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| r |   |   |                     |   |   |   |                        |
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| h |   |   |                     |   |   |   |                        |
| e |   |   |                     |   |   |   |                        |
| r |   |   |                     |   |   |   |                        |
|   |   |   |                     |   |   |   |                        |
| s |   |   |                     |   |   |   |                        |
| u |   |   |                     |   |   |   |                        |
| b |   |   |                     |   |   |   |                        |
| s |   |   |                     |   |   |   |                        |
| t |   |   |                     |   |   |   |                        |
| a |   |   |                     |   |   |   |                        |
| n |   |   |                     |   |   |   |                        |
| c |   |   |                     |   |   |   |                        |
| e |   |   |                     |   |   |   |                        |
| s |   |   |                     |   |   |   |                        |
| ) |   |   |                     |   |   |   |                        |
+---+---+---+---------------------+---+---+---+------------------------+

Please list medical or psychiatric conditions and/or appointments you
have coming up:

+-----------------------------------------------------------------------+
| #####                                                                 |
+-----------------------------------------------------------------------+
| #####                                                                 |
+-----------------------------------------------------------------------+
| #####                                                                 |
+-----------------------------------------------------------------------+
| #####                                                                 |
+-----------------------------------------------------------------------+

**[[Mental Health Treatment History]{.smallcaps}]{.underline}** (include
Hospitalizations, Residential or Outpatient)

+----------------+----------------+----------------+------------------+
| **[Treatment   | #              | ###            | ###### **Treat   |
| Facility]      | ##### **Dates  | ### **Reason f | ment Follow-Up** |
| {.underline}** | of Treatment** | or Treatment** |                  |
+----------------+----------------+----------------+------------------+
|                |                |                |                  |
+----------------+----------------+----------------+------------------+
|                |                |                |                  |
+----------------+----------------+----------------+------------------+
|                |                |                |                  |
+----------------+----------------+----------------+------------------+
|                |                |                |                  |
+----------------+----------------+----------------+------------------+

Medication Information

  ---------------------------- ------------------------------- ------------------------- ---------------------
  **[Current                   **[Amount/dose]{.underline}**   **[Times]{.underline}**   **[Medication taken
  Medications]{.underline}**                                                             for:]{.underline}**

                                                                                         

                                                                                         

                                                                                         

                                                                                         

                                                                                         
  ---------------------------- ------------------------------- ------------------------- ---------------------

Family History

  -----------------------------------------------------------------------
  **Family of Origin** (list parents & siblings, give current age &
  health; if deceased, note age & cause of death)

  **Father**

  **Mother**

  **Siblings**

  **Child hood** (give a short description of significant childhood
  events, include physical or sexual abuse)

  **Have you been a victim of Domestic Abuse?** **Yes** **No** (if yes,
  explain)

  -----------------------------------------------------------------------

Marital History

  -----------------------------------------------------------------------
  Present Status: Married Divorced Widowed Separated Never Married

  Give brief Marital History (include dates & lengths of marriage,
  children, child support and custody status)

  -----------------------------------------------------------------------

Alcohol/Drug History

+--------------+------------+------------+------------+--------------+
| For          |            |            |            |              |
| substances   |            |            |            |              |
| you have     |            |            |            |              |
| experimented |            |            |            |              |
| with or      |            |            |            |              |
| abused,      |            |            |            |              |
| specify      |            |            |            |              |
| dates of     |            |            |            |              |
| first use,   |            |            |            |              |
| peak use,    |            |            |            |              |
| and last     |            |            |            |              |
| use:         |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **[          | ####       | **[Peak    | **[A       | **[Last      |
| Substance]{. | ### Age of | Use]{.sm   | mount]{.sm | Use]{.       |
| smallcaps}** |  First Use | allcaps}** | allcaps}** | smallcaps}** |
+--------------+------------+------------+------------+--------------+
| **Alcohol**  |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| *            |            |            |            |              |
| *Marijuana** |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Cocaine**  |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Crack**    |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Metha      |            |            |            |              |
| mphetamine** |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Speed**    |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Hal        |            |            |            |              |
| lucinogens** |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| *            |            |            |            |              |
| *Inhalants** |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Opoids**   |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Tobacco**  |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| *            |            |            |            |              |
| *Sedatives** |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Pain       |            |            |            |              |
| Killers**    |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Ecstasy**  |            |            |            |              |
+--------------+------------+------------+------------+--------------+
| **Other:**   |            |            |            |              |
+--------------+------------+------------+------------+--------------+

**[[Cage Test]{.underline}]{.smallcaps}** Check appropriate response)

  -----------------------------------------------------------------------
  YES NO Have you ever felt you should cut down on your drinking/drug
  use?

  YES NO Have people ever annoyed you by criticizing your drinking/drug
  use?

  YES NO Have you ever felt bad or guilty about your drinking or drug
  use?

  YES NO Have you ever drank in the A.M. to steady your nerves or relieve
  a hangover?
  -----------------------------------------------------------------------

**[Current Substance Use]{.smallcaps}** (describe substance, frequency,
and quantity)

  -----------------------------------------------------------------------

  **Tolerance** (has it increased or decreased over the past 5 years?)
  Increased Decreased

  **History of Blackouts** (first one, last one):

  -----------------------------------------------------------------------

Substance Treatment and/or Detox

+-----------------+-----------------+-----------------+-----------------+
| ######## Tre    | **[Dates        | **[Length of    | **[AA/NA        |
| atment Facility | ]{.smallcaps}** | Sobriety after  | Attendance      |
|                 |                 | Discharge       | after           |
|                 |                 | ]{.smallcaps}** | Discharge       |
|                 |                 |                 | ]{.smallcaps}** |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+

**[History of Alcohol/Drug Withdrawal Symptoms]{.smallcaps}** (check all
that apply)

  ----------------- ------------ -------------- -------------- --------------
  Hallucinations    Seizures     DT's           Tremors        Convulsions

  Nausea            Other                                      
                    (specify)                                  
  ----------------- ------------ -------------- -------------- --------------

**[[Issues Other than Substance Related]{.underline}]{.smallcaps}**
(please check all that apply)

+-----------------------------------------------------------------------+
| Sleep problems Concentration problems Memory loss PTSD from combat    |
| Pain                                                                  |
|                                                                       |
| Seizures Gambling Eating Sexual Schizophrenia Fear of people Anger    |
|                                                                       |
| Non- combat PTSD Social relationships Self-esteem Depression          |
| Authority                                                             |
+-----------------------------------------------------------------------+

# HIV (AIDS) Risk Assessment

+-----------------------------------------------------------------------+
| What is your sexual orientation? Heterosexual Bisexual Homosexual     |
|                                                                       |
| Do you have satisfying sexual experiences? Yes No Sometimes           |
|                                                                       |
| If you do IV drugs, do you share needles? Yes No Sometimes            |
|                                                                       |
| Do you participate in unprotected sex? Yes No Sometimes               |
|                                                                       |
| Have you ever been tested for HIV/AIDS? Yes No                        |
|                                                                       |
| While here, would you like to be tested for HIV? Yes No               |
|                                                                       |
| When was your most recent unprotected sexual experience?              |
| \_\                                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| How many different sexual partners have you had in the past 10 years? |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}  |
|                                                                       |
| Have you had any blood transfusions in the 10 years? Yes No           |
|                                                                       |
| Briefly, summarize your knowledge of aids transmission and            |
| prevention.                                                           |
+-----------------------------------------------------------------------+

Legal History and Status

+-----------------------------------------------------------------------+
| Explain current legal problems and status:                            |
|                                                                       |
| Have you ever been arrested? (check one)                              |
|                                                                       |
| No Yes, once Yes 2-5 times Yes 6-10 times Yes, more than 10 times     |
|                                                                       |
| Have you ever been incarcerated (jail or prison)? Yes No              |
|                                                                       |
| If yes, how long and what charge?                                     |
|                                                                       |
| Do you have any outstanding warrants? Yes No Not sure                 |
|                                                                       |
| Would you consent to a warrant check? Yes No                          |
|                                                                       |
| Are you required to register on the State of Alaska sex offender      |
| list? Yes No                                                          |
|                                                                       |
| Do you have a driver's license? Yes No                                |
|                                                                       |
| If not, why not?                                                      |
| [\_\_\_\_\_\_\_\_\                                                    |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Do you have a vehicle? Yes No Make:                                   |
| [\_\_\_\_\_\_\_\_\_\_]{.underline} Model                              |
| [\_\_\_\_\_\_\_\_\_\_]{.underline} Year                               |
| [\_\_\_\_\_\_\_\_\_\_]{.underline}                                    |
|                                                                       |
| Do you have auto insurance? Yes No Expiration date:                   |
| [\_\_\_                                                               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Do you have a current registration? Yes No Expiration date:           |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}    |
+-----------------------------------------------------------------------+

Financial Assessment

+-----------------------------------------------------------------------+
| How much money did you receive in the past 30 days? (include all      |
| sources of income: work, disability payments, panhandling, pawns,     |
| plasma donations, etc.)                                               |
|                                                                       |
| No income at all \$1 - \$49 \$50 - \$99 \$100 - \$499 \$500 - \$999   |
|                                                                       |
| \$1000 or more                                                        |
|                                                                       |
| In you life, what year were your greatest employment earnings?        |
| \_\_\_\_\_\_\_\_\_\_ How much? \_\_\_\_\_\_\_\_\_\_/yr                |
|                                                                       |
| What vocation (type of work has been your main source of income for   |
| the last 10 years?                                                    |
|                                                                       |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                        |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
+-----------------------------------------------------------------------+

**[[Money Management]{.underline}]{.smallcaps}** (Please describe your
abilities in each category)

+-----------------------------------------------------------------------+
| Describe your ability to manage money: Good Poor Sporadic Need        |
| assistance                                                            |
|                                                                       |
| Lending/Borrowing: Good Poor Sporadic Need assistance                 |
|                                                                       |
| Saving: Good Poor Sporadic Need assistance                            |
|                                                                       |
| Experience with a budget: None Some Good Poor Sporadic Need           |
| assistance                                                            |
+-----------------------------------------------------------------------+

Income/Finances

+-----------------------------------------------------------------------+
| List sources and amounts of Monthly Income:                           |
|                                                                       |
| Employment: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} SSI:       |
| [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} Social Security:       |
| [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}                        |
|                                                                       |
| VA Pension: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} VA Service |
| Connection: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} Food       |
| Stamps [\_\_\_\_\_\_\_\_\_\_]{.underline}                             |
|                                                                       |
| Railroad Retirement: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}   |
| Other Retirement: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}      |
| Family: [\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}                      |
|                                                                       |
| Workman's Comp: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}        |
| Unemployment: [\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} Other    |
| sources: [\$\_\_\_\_\_\_\_\_\_]{.underline}                           |
|                                                                       |
| Do you have an application pending for disability or adult public     |
| assistance? Yes No                                                    |
|                                                                       |
| If yes, with whom and what is the status?                             |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Do you have a bank account? Yes No                                    |
|                                                                       |
| As of today, how much money do you have? \$                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                |
|                                                                       |
| List All Debts                                                        |
|                                                                       |
| Medical \$ [\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} Landlords \$    |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} Credit Cards \$          |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}                          |
|                                                                       |
| Utilities \$ [\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} Phone \$      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ IRS \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  |
|                                                                       |
| Auto \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ School \$                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Insurance \$                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                        |
|                                                                       |
| Child Support \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Other                   |
| \_\_\_\_\_\_\_\_\_\_\_\                                               |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |
| Other                                                                 |
| [\_\_\_\_\_\_\_\_\_\_                                                 |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
+-----------------------------------------------------------------------+

######### Social Issues

+-----------------------------------------------------------------------+
| Names of Social/Family Contacts:                                      |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                        |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                        |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Memberships in Organizations (clubs, fraternity, gym, social, etc.):  |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                   |
| \_\_\_\_\_]{.underline}                                               |
|                                                                       |
| [\_\_\_\_\_\_\_\_\_\_\_                                               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_]{.underline}                                                 |
|                                                                       |
| Hobbies/Interests:                                                    |
| [\_\_\_\_\_\_\_\                                                      |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

Education/Vocational

+-----------------------------------------------------------------------+
| Highest Grade Completed: Jr. High 10^th^ grade 11^th^ grade GED High  |
| School                                                                |
|                                                                       |
| 1 year college 2 years college 3 years college 4 years college 5      |
| years college                                                         |
|                                                                       |
| 6 years college AA/AS Degree Bachelor's Degree Master's Degree        |
| Certificate                                                           |
|                                                                       |
| College Major:                                                        |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} College    |
| Minor:                                                                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      |
|                                                                       |
| Military/Technical Training:                                          |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Vocational/Apprentice Training:                                       |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Computer Experience:                                                  |
| [\_\_\_\_\                                                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| What programs/software do you have experience with?                   |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_                                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| Are you interested in learning more about computers? Yes No           |
|                                                                       |
| Would you like job/educational training? Yes No                       |
|                                                                       |
| If yes, would you **like** to do?                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                                 |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

Time Management

+-----------------------------------------------------------------------+
| Check which answer best describes your timeliness for meetings and    |
| appointments:                                                         |
|                                                                       |
| Always early Sometimes early Always on time Sometimes on time Rarely  |
| on time                                                               |
+-----------------------------------------------------------------------+
| Check which answer best describes your timeliness for meeting task    |
| completion deadlines:                                                 |
|                                                                       |
| Always early Sometimes early Always on time Sometimes on time Rarely  |
| on time                                                               |
+-----------------------------------------------------------------------+
| Do you ever procrastinate? Often Sometimes Rarely Never               |
|                                                                       |
| If often or sometimes, about what type of things?                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

Religious Activity

+-----------------------------------------------------------------------+
| #### **Religious Preference:**  Catholic  Protestant  Jew             |
| ish  Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### How often do you attend religious services?                      |
|                                                                       |
| Never Major Holidays only More than 4 times a year Weekly More than   |
| once a week                                                           |
+-----------------------------------------------------------------------+
| #### How much is religion a source of strength and comfort to you?    |
|                                                                       |
| Not at all Slightly Quite a bit A great deal                          |
+-----------------------------------------------------------------------+
| #### Does your church/synagogue play a role in your life?             |
|                                                                       |
| Not at all Slightly Quite a bit A great deal                          |
+-----------------------------------------------------------------------+
| #### Do you wish to have                                              |
| a specific clergy member or religious organization contacted for you? |
|                                                                       |
| No Yes, explain:                                                      |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
+-----------------------------------------------------------------------+

Spiritual Activity

+-----------------------------------------------------------------------+
| ####                                                                  |
| Do you consider yourself to be a spiritual person?  Yes  No  Somewhat |
|                                                                       |
| **How do you express yourself spiritually? Prayer?** Yes No           |
|                                                                       |
| **How often do you pray privately?**                                  |
|                                                                       |
| Never Occasionally (at least once a week)                             |
|                                                                       |
| Regularly (once a day or more) Frequently (twice a day or more)       |
|                                                                       |
| **How often do you read scriptural or spiritual literature?**         |
|                                                                       |
| Never Occasionally (at least once a week)                             |
|                                                                       |
| Regularly (once a day or more) Frequently (twice a day or more)       |
|                                                                       |
| **How often do you listen to spiritual/religious programs on radio or |
| TV?**                                                                 |
|                                                                       |
| Never Monthly Weekly Once a day Twice a day or more                   |
|                                                                       |
| **How often do you study the bible or other spiritual/religious       |
| text?**                                                               |
|                                                                       |
| Never Monthly Weekly Once a day Twice a day or more                   |
|                                                                       |
| **How important is spiritual expression to you?**                     |
|                                                                       |
| Not at all Slightly Quite Very important                              |
|                                                                       |
| **In my life, I experience the presence of the Devine (i.e., God,     |
| Higher Power, Creator, Great Spirit).**                               |
|                                                                       |
| Definitely not true Tends not to be true Unsure Tends to be true      |
| Definitely true                                                       |
|                                                                       |
| **My beliefs/philosophy are what really lie behind my whole approach  |
| to life.**                                                            |
|                                                                       |
| Definitely not true Tends not to be true Unsure Tends to be true      |
| Definitely true                                                       |
|                                                                       |
| **I try to carry my beliefs over into all other dealings in life.**   |
|                                                                       |
| Definitely not true Tends not to be true Unsure Tends to be true      |
| Definitely true                                                       |
+-----------------------------------------------------------------------+

Cultural / ethnic

+-----------------------------------------------------------------------+
| **Do you have any special cultural/ethnic practices related to        |
| worship (i.e., sweat lodges, sage, pipe)**                            |
|                                                                       |
| No Yes, explain:                                                      |
| [\_\_\                                                                |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| #### Do you have special dietary practices related to your religion?  |
|                                                                       |
| No Yes, explain:                                                      |
| [\_\_\                                                                |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| #### Do you have any                                                  |
| religious/spiritual beliefs that would affect your medical treatment? |
|                                                                       |
| No Yes, explain:                                                      |
| [\_\_\                                                                |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
|                                                                       |
| #### Do you have any religious/spiritual beliefs related to death?    |
|                                                                       |
| No Yes, explain:                                                      |
| [\_\_\                                                                |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline} |
+-----------------------------------------------------------------------+

Spiritual Injuries

+-----------------------------------------------------------------------+
| **How often do you feel guilty over past behaviors?**                 |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### Does anger or resentment block your peace of mind?               |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### How often do you feel sad o0r experience grief?                  |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### How often do you feel despair or hopelessness?                   |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### Do you feel that life has no meaning or purpose?                 |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### Do you worry about doubts or disbelief in God?                   |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### Do you worry about death?                                        |
|                                                                       |
| Often Sometimes Very often Never                                      |
|                                                                       |
| #### Do you feel that God/life has treated you unfairly?              |
|                                                                       |
| Often Sometimes Very often Never                                      |
+-----------------------------------------------------------------------+

Personal Treatment Factors

+-----------------------------------------------------------------------+
| # [What are your strengths?]{.smallcaps}                              |
+-----------------------------------------------------------------------+
| #                                                                     |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| **[What are your preferences?]{.smallcaps}**                          |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| **[List obstacles to your recovery:]{.smallcaps}**                    |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| **[List your abilities:]{.smallcaps}**                                |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  **[I certify that the information I provided on this form and in my
  interview is complete and accurate. I understand that any information
  that is determined to be false is sufficient grounds for refusal of
  admission.]{.smallcaps}**

  -----------------------------------------------------------------------

**[Veteran's Signature:]{.smallcaps}**

**[Date:]{.smallcaps}**

**[Referral Source]{.smallcaps}** (if applicable) please print

  -----------------------------------------------------------------------
  **[Agency:]{.smallcaps}**

  **[Clinician: Phone:]{.smallcaps}**
  -----------------------------------------------------------------------