Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone

(###)

###

####

Current Parenting Situation *

Choose one

Full Custody of Children

Children with Family

Children in Temporary Foster Care

Children in Permanent Placement

Not Applicable

Income Situation *

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No Income

Inadequate income and/or spontaneous/inappropriate spending

Can meet basic needs with subsidy; appropriate spending

Can meet basic needs and manage finances without assistance

Employment Situation *

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Unemployed

Temporary, part time, or seasonal employment. Inadequate pay, no benefits

Employed full time; inadequate pay, few or no benefits

Employed full time with adequate pay and benefits

Housing Situation *

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Homeless or Unfit housing

In temporary housing (hotel, hospital, mental health facility, jail, etc.)

In transitional housing (i.e. long term housing program) or other stable housing situations.

Housing is safe, adequate, and subsidized (i.e. section 8)

Legal Situation *

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Current outstanding tickets, warrants or other serious unresolved legal issues

Charges/trial pending, non-compliance with probation/parole, legal issues impacting household

Compliant with any past issues. Past felonies impact household.

Completed probation/parole; addressed legal issues. No new charges

No active criminal justice involvement for over 1 year or no criminal history.

Access to Health Care *

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No medical coverage with an immediate need (i.e. prenatal care)

No medical coverage but able to address medical needs

Some members (i.e. child) have medical coverage

All members of household can get medical care when needed

All members have adequate medical coverage.

Substance Abuse *

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Severe active abuse/dependency

Use within 30 days. In withdrawal or involvement with drugs or alcohol.

1-6 months sobriety but lack support

1-6 months sobriety with support and strategies for ongoing sobriety

no addiction issues OR 6+ months of sobriety with ongoing plan

Safety *

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Fears for immediate safety and well being

Safety is threatened; sense of safety due to temporal circumstances.

Have minimal adequate sense of safety. Have participated in a safety planning workshop

Have a frequent sense of safety but future safety is uncertain

Environment is safe and stable