Are you receiving assisted help in reading or writing this application? (circle one)
If yes: Name of assistant
Religious Affiliation (Not a requirement, just to know)
Are you pregnant?
Do you have a car?
Do you have your High School Diploma?
Are you currently incarcerated or on parole?
Are you employed?
Do you receive SSI benefits?
Do you receive food stamps (EBT card)?
Where have you lived the majority of your life up until recently? (Have you lived in the area? Placements?)
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?
Are you able to provide your two most recent exams?
Do you have health insurance?
Are you currently prescribed any medications?
What are your prescribed medications
Are you currently actively taking your medication? If not, why?
Do you have a history of drug/substance abuse?
We would like to know in order to help you get proper services
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?