Adult Intake Form
Please complete this form prior to your first appointment. If you have not contacted New Directions before and are interested in services staff will contact you via the information provided on the form.
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Email *
Name *
Date of birth *
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Gender *
What pronouns do you prefer? *
Required
Do you identify as LGBTQIA+? *
What racial and ethnic groups do you identify with? *
What is your marital status? *
What is the highest level of education you completed? *
Are you disabled? *
Do you have health insurance? If so, who is it through? *
Are you receiving any government benefits? If so, please list the type and amounts for each. Government benefits include: TANF, SNAP, SSI, SSDI, VA Service Connected Disability Compensation, VA Non-Service Connected Disability Pension, Private Disability Income, Worker's Compensation, SS Retirement, Pension, Child Support, Alimony or Spousal Support, Unemployment Insurance. *
What is your military status? *
What is your home address? Please include city, state, and zip code. *
What type of housing are you in? *
What is the best phone number to reach you at and is this a safe number to leave a voicemail with? *
Are you currently employed? *
If so, where are you employed at? *
What is your monthly income? *
What type of employment do you hold? *
What is your family type? *
How do you prefer to be contacted? *
Do you have children? If so please list their genders and ages. *
How did you hear about us? *
What are your presenting problems and how long have they been going on? *
In the last year have you had any life changes or stressors? *
Do you have any medical or mental health conditions? If so, please specify. *
Do you currently use alcohol or drugs? If so, what do you use and how long have you been using it? *
Do you have a past history of alcohol and/or drug use? If so, what did you use, how long did you use, and when did you stop using? *
Have you received treatment for substance use or mental health? If so, please specify which one, where it was at, and when you received treatment. *
Are you having thoughts of suicide or harming yourself? If so, please explain. *
Do you have a history of experience in child abuse, sexual assault, or neglect? If so, please explain. *
Are you currently in or have you experienced a relationship that involved sexual or domestic violence? If so, please explain. *
Have you ever experience a situation where you felt exploited or were unable to leave the situation/relationship (currently or in the past)? If yes, please explain. *
What is the perpetrators relationship to you? *
Is this a current or former relationship? *
How long is/was the relationship? *
What is the perpetrators age? *
What are the perpetrators racial and ethnic identities? *
Do you have children in common? *
Where did the abuse take place? *
Does the perpetrator have access to weapons? *
Is the perpetrator associated with the military, law enforcement, or the legal system? *
Has the perpetrator ever threatened to use a firearm against you? *
Has the perpetrator ever threatened to use a firearm against your child(ren) *
Has the perpetrator ever threated to destroy your property? *
If you are currently experiencing domestic violence, sexual violence, human trafficking, or stalking, do you have a safety plan? *
Please select all services you are interested in receiving. *
Required
Is there any other important information you would like to share with staff? *
By typing your name you consent to be contacted by a staff member of the New Directions Center. *
A copy of your responses will be emailed to the address you provided.
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