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Laura Canseler School of Technology
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Assessment Form
Assessment Form
Intake Date
Referral Agency
Referral Source Name
Client Name
Date of Birth
Age
Social Security Number
Address
Email
Contact Number
Gender
Race/Ethnicity
African American/Black
Latino
White
Biracial
Asian/Pacific Islander
Religion
Jewish
Christian
Muslim
Unaffiliated
Emergency contact Name
Emergency contact Number
Emergency Contact Relationship
Family Information
Closer Walk Home Re-Entry and Advocacy Program has my permission to contact any of my extended family for additional information or to assess their need for service. I have reviewed and agreed
Date
Are you in contact with any of you friends or family
Yes
no
Father's Name
Father's Address
Father's Number
Mother's Name
Mother's Address
Mother's Number
Parental Relationship Status
Married
Divorce
Separated
domestic Partnership
Additional Information
Significant Other Name
Do you have any Children?
Children Name
Date of birth
Address
contact Number
friend Full Name
Friend Address
Friend contact Information
Long term Disablility
Yes
No
Housing Status: where did you stay last Night
Do you have medical insurance
yes
no
do you smoke
yes
no
where did you live before becoming incarcerated?
What Prison Ceter were you recently released from?
Probation/Parole Officer Name
PO Contact Number
reason for Incarceration (Check all that apply)
Addiction Related
White Collar Crime
Con/Fraud
Domestic Abuse
Violent Crime
Mental Health Related
Sex Offense
Murder
Prison Sentence
Less than 3 years
3 to 5 years
6 to 10 years
11 to 15 years
More than 15 years
Date of Release from prison
Date of Parole/Probation
Release Date from house Arrest or Halfway House
Will you be required to wear an ankle monitor or bracelet
Yes
No
Do you have any other restrictions, warrants or restraining orders placed against you?
Yes
No
If so could you name them?
Heva you ever had any mental health hospitalizations?
Yes
No
Are you under the care of a mental health provider or social worker?
Yes
No
If needed, are you willing to be refered to one upon release?
Yes
No
Have you recieved drug treatment before?
Yes
No
Highest Education Level Completed
Elementary School
High School
Vocational/Trede Schoool
College Degree
Advanced College Degree
Previous Occupation
Are you Currently Employed
Yes
No
Are you a Veteran
Yes
No
Do you have a DD214
Yes
No
STEP #3
did you recieve any vocational/trade traing
Name of training program and service provider
Do you fee this traing helped you? Please specify
What other serviced were provided to you whil incarcerated?
Visitation
Advocacy
Library
How did the service checked helpo you? Please explain
How can Closer Walk Re-entry and advocacy Program help you?
Employment
Training
Housing
Family Support
Counseling
Clothing
Phone
Food
Medical Insurance
Social Security Benefits
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