Intervention & Services ApplicationApplication Information: Complete the following form for the person applying for Intervention and Service assistance. Name: * First Name Last Name Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Email: * Phone: * (###) ### #### Drivers License #/I.D. # * Last 4 of SSN * Age: * Date of Birth * MM/DD/YEAR Race: * Asian Black/African American Native American Caucasian Other Gender: * Male Female Trans Other Ethnicity: * Hispanic Non Hispanic U.S. Citizen: * Yes No Sexual Orientation: * Marital Status: * Single Married Disability: * Health Insurance: * Charge/Offense: * Highest Level of Education: * Employment Status: * Employed Unemployed Primary Source of Income: * Monthly Income Before Taxes: * LineHealth-Related Social Needs Assessment What is your housing situation today? I have a steady place to live I have a place to live today, but I am worried about losing it in the future I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a bench, in a car, abandoned building, bus station, or in a park.) Think about the place you live. Do you have problems with any of the following? Pests such as bugs, ants, or mice Mold Lead paint or pipes Lack of heat Oven or stove not working Smoke detectors missing or not working Water leaks None of the above Food Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, OR NEVER true for you and your household in the last 12 months. Within the past 12 months, you worried that your food would run out before you got money to buy more. Often true Sometimes true Never true Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. Often true Sometimes true Never true Transportation In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? Yes No Utilities In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? Yes No Interpersonal Safety Because violence and abuse happens to a lot of people and affects their health we are asking the following questions. How often does anyone, including family and friends, physically hurt you? Never Rarely Sometimes Fairly often Frequently How often does anyone, including family and friends, insult or talk down to you? Never Rarely Sometimes Fairly often Frequently How often does anyone, including family and friends, threaten to harm you? Never Rarely Sometimes Fairly often Frequently How often does anyone, including family and friends, scream or curse at you? Never Rarely Sometimes Fairly often Frequently Financial Strain How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Very hard Somewhat hard Not hard at all Employment Do you want help finding or keeping work or a job? Yes, help finding work Yes, help keeping work I do not need or want help Family and Community Support If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need? I don’t need any help I get all the help I need I could use a little more help I need a lot more help How often do you feel lonely or isolated from those around you? Never Rarely Sometimes Often Always Employment Do you speak another language other than English at home? Yes No Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent. Yes No Physical Activity In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)? 1 2 3 4 5 6 7 On average, how many minutes did you usually spend exercising at this level on one of those days? 0 10 20 30 40 50 60 90 120 150 Substance Abuse The next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Never Once or Twice Monthly Weekly Daily or almost daily How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Never Once or Twice Monthly Weekly Daily or almost daily How many times in the past year have you used prescription drugs for non-medical reasons? Never Once or twice Monthly Weekly Daily to almost daily How many times in the past year have you used illegal drugs? Never Once or twice Monthly Weekly Daily or almost daily Mental Health Over the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things? Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3) Feeling down, depressed, or hopeless? Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3) Little interest or pleasure in doing things? Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3) Disabilities Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?20 (5 years old or older) Yes No Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?21 (15 years old or older) Yes No Ohio Risk Assessment System: Misdemeanor Assessment Tool (ORAS-MAT) Most serious arrest under age 18. 0 = None 1 = Yes, Misdemeanor 2 = Yes, Felony Number of prior adult felony convictions. 0 = None 1 = One or Two 2 = Three or more Highest education 0 = High school graduate or higher 1 = Less than high school or GED Ever suspended or expelled from school 0 = No 1 = Yes Currently employed/school 0 = Yes, FT, disabled, or retired 1 = Not employed or employed PT Better use of time 0 = No, most time structured 1 = Yes, lots of free time Drug use caused problems None 0 = Past 1 = Current Drug use caused problems with employment 0 = No 1 = Yes Current offense heroin related 0 = No 1 = Yes Criminal friends 0 = None 1 = Some 2 = Majority Contact with past criminal peers 0 = No contact 1 = at risk of contact 2 = contact or activity seeks criminal peers Criminal attitudes 0 = No/limited criminal attitudes 1 = some criminal attitudes 2 = Significant criminal attitudes Today's Date: * MM DD YYYY E- Signature: Your application has been submitted!
