SOCIAL INTAKE FORM

Purpose: To determine the psycho-social needs of students and make appropriate referrals and case management plans.

DEMOGRAPHIC INFORMATION
Student Name:	Student ID:
DOE:	DOB:	Age:
FAMILY BACKGROUND
Mother/Guardian	Father/Guardian
Name:	Name:
Address:	Address:
City:	City:
State:	State:
Zip Code:	Zip Code:
Phone #:	Phone #:
Do you have any siblings?	Yes No	If yes, how many:
Do you have any children?	Yes No	If yes, how many:
Provide children’s name(s) and age(s): Name: Age: Name: Age: Name: Age: Name: Age:
Has the Job Corps child allotment been explained to you?	Yes No	Who is the day care provider for your child(ren)?
Who raised you?	Whom have you lived with for the past year?
How long have you lived there?	Do you like living there?	Yes No
If a minor, do you live with your parent?	Yes No	If no, the reason is:
Do you have a caseworker?	Yes No	If yes, caseworker’s name: Phone #:
Military/Discharge Type:
Describe your relationship with the following people (e.g., excellent, good, fair, poor, none): Mother/guardian: Father/guardian: Siblings: Significant other/spouse: Friends: Others (e.g., teachers, bosses, etc.):
LEGAL ISSUES
Have you ever been in trouble with the police?	Yes No	If yes, for what and when (year):
Are you presently awaiting charges, court, or sentencing?	Yes No	If yes, for what:
Are you currently on probation?	Yes No	If yes, provide probation officer’s information Name: Phone #: Address: City, State, Zip Code:
EDUCATION BACKGROUND
Did you receive any special education or resource classes?	Yes No	If yes, in what areas and when (years)?
If you did not complete school why did you stop and when (year)?
Were you ever suspended or expelled?	Yes No	If yes, how many times and reason(s):
WELLNESS SUPPORT
Job Corps wants to support you with your career goals. Often, personal issues can interfere with your career goals. Job Corps offers a full program of support. Information will be confidential and shared only with staff/agencies with a need to know as required by Job Corps or state laws.
Have you ever been to see a psychologist, therapist, psychiatrist, counselor, or social worker, or been in any kind of counseling before?	Yes No	If yes, for what reason and when (years): How many times? Approximate date of last appointment:
Have you ever received or taken any medicine to help you with feeling sad, worrying, having trouble paying attention, or for behavior?	Yes No	If yes, when (year)? What was the medicine? Who gave it to you? How long did you take it?
EMOTIONAL WELLNESS
Are you NOW (e.g., last few days or weeks) having any of the following: (Check all that apply)
Depression	Having sleep or appetite problems Having low energy Wanting to be alone more than usual Crying often Feeling sad or hopeless None reported
Poor Self-esteem	Feeling worthless Feeling you cannot do anything right Putting yourself down None reported
Suicidal Thoughts/Ideas	Thoughts of hurting or killing yourself Have a plan to hurt or kill yourself Have access to a way to hurt or kill yourself None reported
Homicidal Thoughts/ Ideas	Thoughts of hurting or killing someone Have a plan to hurt or kill someone None reported
Anger issues	Getting easily irritated Punching the wall or things Punching people or animals Having a bad temper or trouble controlling violent behavior None reported How would you respond to someone disrespecting you?
Grief (Feeling sad about or dealing with loss)	Family member Friend Someone else you were close to or knew None reported
Anxiety	Feeling stressed out or fearful Having panic attacks Often feeling very worried None reported
Auditory or Visual Hallucinations	Hearing voices when no one else is around Seeing things that other people around you do not see None reported
Self-Injury Behaviors	Cutting Burning Other ways (specify) None reported
Sleep Problems	Nightmares Having trouble falling or staying asleep Wetting the bed None reported
Attention or Concentration Issues	ADD ADHD (Attention-Deficit/Hyperactivity Disorder) Having too much energy Acting without thinking Can’t sit still Can’t complete tasks Get bored very fast None reported
Eating Issues	Starving yourself Eating in secret Over eating Making yourself throw up Bingeing Eating till you feel sick Using laxatives to control weight Exercising out of control (>3 hours or exercising to the point that you miss work/school) None reported
Sexual/Sexuality Issues	Having sex recklessly with anyone Feeling bad about sexual thoughts or feelings Feeling confused or concerned about sexual orientation/gender None reported
Relationship Issues	With: Family Partner Friends Gang members None reported
Parenting Issues	Fighting with your child’s other parent Feeling fearful of abusing your child Feeling overwhelmed by child-rearing responsibilities None reported
EMOTIONAL WELLNESS
Have you EVER experienced any of the following:
Bullying or been accused of bullying?	Yes No If yes, please explain:
Abuse, Verbal Abuse, Sexual Abuse or Physical Abuse?	Yes No If yes, what type of abuse and when (years)? Did the abuse stop? Yes No Month and year?
An event that was so frightening, horrible, or upsetting that you:	Had nightmares about it or thought about it when you did not want to Tried hard not to think about it or went out of your way to avoid situations that reminded you of it Were constantly on guard, watchful, or easily startled None reported
Thoughts of hurting or killing yourself but did not go to see anyone for help?	Yes No If yes, when (month and year)? Did you try to hurt or kill yourself? Yes No What problems made you feel suicidal? Do you feel these problems have gone away? Yes No
Have you ever gone to the emergency room or been admitted to the hospital for any of the above problems?	Yes No If yes, when (years)? What hospital? How long did you stay there? Was it helpful? Yes No
ALCOHOL AND DRUGS
During the past 12 months have you:
1. Drank any alcohol (more than a few sips)?	Yes No
2. Smoked any marijuana?	Yes No
3. Used anything else to get "high"?	Yes No
If you answered NO to all three questions answer Question 4 only. If you answered YES to any of the above questions answer Questions 4 through 6.
4. Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?	Yes No
5. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?	Yes No
6. Do you ever use alcohol/drugs while you are by yourself, ALONE?	Yes No
If you answered NO to these questions skip the next four questions. If you answered YES to any of the above questions answer Questions 7 through 10.
7. Do you ever FORGET things you did while using alcohol or drugs?	Yes No
8. Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?	Yes No
9. Have you gotten into TROUBLE while you were using alcohol or drugs?	Yes No
10. Are you bothered by a friend/family member/partner’s alcohol or drug use?	Yes No
11. In the past three months have you used any type of tobacco product?	Yes No
PROTECTIVE FACTORS
When you are upset, what helps you relax?
What is your favorite thing to do in your free time?
Are you religious?	Yes No Which religion/faith, if any?
What do you consider your strengths/talents?
Do you want assistance in dealing with any of the behaviors checked on this form?	Yes (Complete next readiness section) No (I understand that I may seek help at any time – Skip next readiness section)
READINESS SCALE/READINESS FOR CHANGE
If you want help, how ready are you to consider changing any of the behaviors checked on this form? 0 1 2 3 4 5 6 7 8 9 10 Not Ready Thinking About It Ready
How can we be helpful to you at this time in making a change right now?

Student Signature	Date

Counselor Signature	Date

Reviewed by:

Counseling Manager	Date

Center Mental Health Consultant, if applicable	Date

TEAP Specialist	Date

Items for Intervention Plan:

TEAP REFERRAL	SPECIAL GROUPS	TUPP REFERRAL	ACADEMIC REFERRAL

MENTAL HEALTH REFERRAL	RECREATION REFERRAL	HEALS REFERRAL	PHYSICIAN REFERRAL

Assigned to:

Group(s):

Comments regarding student’s motivation and needs:

CRAFFT-Massachusetts Department of Public Health Bureau of Substance Abuse Services. Boston, MA. Massachusetts Department of Public Health, 2009.