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Social History
Home
Social History
Name
Race
Marital Status:
Sex
Male
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?
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