Social History

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Social History

Name

Race

Marital Status:

Sex

Birthdate

Are you receiving assisted help in reading or writing this application? (circle one)

Yes NO

If yes: Name of assistant

Religious Affiliation (Not a requirement, just to know)

Are you pregnant?

NO Yes

Do you have a car?

Yes No

Do you have your High School Diploma?

No Yes

Are you currently incarcerated or on parole?

No Yes

Income

Are you employed?

No Yes

Do you receive SSI benefits?

No Yes

Do you receive food stamps (EBT card)?

Yes No

Housing History

Where have you lived the majority of your life up until recently? (Have you lived in the area? Placements?)

Medical History

Do you know if you or any of your biological family have any health problems/history?

Do you know if you or any of your biological family have any mental health problems/history?

Have you taken a Mental Health Exam?

Yes No

Are you able to provide your two most recent exams?

Do you have health insurance?

Yes No

Are you currently prescribed any medications?

Yes No

What are your prescribed medications

Are you currently actively taking your medication? If not, why?

Do you have a history of drug/substance abuse?

Yes No

We would like to know in order to help you get proper services

Social History

How do you take care of your emotional well-being?

Who are the greatest supports in your life? How have they helped you

Who is your greatest confidant? Who do you feel you can talk about anything to?

At what age were you put into your first placement? How many placements have you been to since then?

What has been your experiences/thoughts/feelings with your placements?

What are your greatest strengths?

What are areas of your life that you would like to improve/work on?

What are the major stressors in your life right now?

Do you know of any triggers that our staff should be made aware of?

What are your hobbies/ interests?

Do you have any educational goals?

Do you have any career goals?

Do you have any short term goals?

Do you have any career/long term goals?

What are your greatest achievements?

Why do you think River Jordan is a good fit for you?

Where do you see yourself after utilizing River Jordan services?

Empowering current and former foster youth to take responsibility of their own individual lives and become productive members of society.

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3442 Kiesel Road Bay City, Michigan 48706
(989) 391-4046
intake@riverjordaninc.org

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