Briarpatch Street Outreach Needs Assessment
Please answer as many questions as possible.  Once submitted our staff will review and schedule an intake for services.  Due to an increase in referrals and a reduction in staffing, it may take 3-7 business days for us to respond.    Note: We do not provide housing, we work with individuals to identify attainable shelter and housing options based on their needs, risks, and ability.  


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Email *
First Name *
Last Name *
Preferred pronouns
Clear selection
How did you hear about Briarpatch Street Outreach?
Did you age out of Foster Care or Juvenile Corrections?
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Do you feel safe?
What is your age?
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What is your preferred language?
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What is the best way to communicate with you? *
Phone number *
email address
Can we text you? *
What is your preferred gender identity?
Clear selection
Are you currently pregnant or an expecting parent?
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Do you have children?
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Names of Children (first last and age)
Do you have children that are not in your care?
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If a group existed that provided support to young adult parents (mothers / fathers / both), would you be interested in participating?
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Where are you sleeping most frequently?
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Is your current housing situation stable?
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How long can you stay at your current housing?
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If necessary, would you sleep in the Emergency Shelter?
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Would you say that you have enough to eat?
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Do you have Foodshare?
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What forms of transportation do you use?
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Do you have a drivers license?
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Do you have a vehicle?
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What forms of ID do you have? *
Required
Do you have any legal issues going on right now?  (on papers, owe money to court, pending charges, etc.)
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What is your current work / income?
Do you have debt, or credit issues?
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What is your school situation?
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Do you have health insurance / Badgercare
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Are their medications you take or should take?
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Have you been in a situation where you felt like you were sexually exploited or exploited for money, food, shelter?
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How many times have you been physically threatened or physically harmed
Have you made attempts to kill yourself?
Clear selection
Have you thought about harming yourself or thought you'd be better off dead?
Clear selection
Have you been hospitalized for harming yourself?
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Have you thought about or attempted to harm someone else?
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Do you feel?
Are you using controlled substances? (drugs, alcohol)
Are you concerned about your use?
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Have you been a victim of crime?
What do you identify as your best quality?
Do you have a religious or spiritual practice?
Clear selection
Rate your current feeling
Frustrated and angry
Feeling great
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Identify one life goal
What do you feel is the most important thing we should know about you?
Submit
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