FORT BRAGG POLICE DEPARTMENT ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 250 Cypress Street Eric Swift (707) 961-2800 Fort Bragg, CA 95437-5437 Chief of Police Fax: (707) 961-2806 ________________________________________________________________________________________________________________________________________________________________________________________________________________________
SCREENING AND NEEDS ASSESSMENT
CONTACT INFORMATION
FULL NAME:_____________________________________ DOB:_____________ AGE:_______ GENDER:_______________ SEXUAL ORIENTATION:_____________ MARTIAL STATUS:____________ PRIMARY LANGUAGE:_____________ RACE/ETHNICITY:________ MILITARY STATUS:___________ REFERRAL SOURCE:_____________________________________ # OF POLICE CONTACTS ________ PRIOR CONVICTIONS/PROBATION:___________________________ EDUCATION:__________________ CURRENT ADDRESS/SHELTER:_____________________________________________________________ PRIMARY PHONE:_______________________ MESSAGE PHONE:_____________________________ EMERGENCY CONTACT:______________________ PHONE:__________
HOUSING STATUS
HOUSED/SHELTERED RISK OF HOMELESSNESS SHAPE \* MERGEFORMAT HOMELESS/UNSHELTERED MINORS- LIVING SITUATION:___________________________________________________
MENTAL HEALTH/ CO-OCCURRING INFORMATION
HAVE THEY EVER RECEIVED MENTAL HEALTH SERVICES?:_________ IF YES, WHERE/WHEN:____________________________________________________________________ IF KNOWN, MENTAL HEALTH DIAGNOSIS:__________________________________________________ IF KNOWN, TAKING MENTAL HEALTH MEDICATIONS:_______________________________________ SUDT SERVICES:__________________________________________________________________________ CO-OCCURRING SUBSTANCE USE DISORDER:_______________________________________________
MEDICAL INFORMATION
CURRENT HAVE HEALTH INSURANCE?:___________________________________________________ PRIMARY HEALTH DOCTOR:___________________________IF NONE, NEED TO ESTABLISH CARE CURRENT MEDICATIONS:________________________________________________________________
INCOME/EMPLOYMENT INFORMATION
EMPLOYED:______EARNED INCOME: ___________ SSI/SSDI:__________ OTHER ASSISTANCE:_____
IMMEDIATE NEEDS
COMMUNITY MENTAL HEALTH SHAPE \* MERGEFORMAT SUBSTANCE USE TREATMENT
CASE MANAGEMENT RESIDENTIAL SUPPORTIVE SERVICES
ID/BIRTH CERTIFICATE LEGAL SERVICES
EMPLOYMENT/INCOME CALFRESH/FOOD STAMPS FOOD/MEALS
MEDICAL SERVICES CLOTHING SHOWERS SHAPE \* MERGEFORMAT OTHER
REFERRALS
Will you sign a release of information for all wrap around providers listed below? ______
REFERRAL DATE FOLLOW UP/APPT DATE
Mendocino Coast Hospitality Center _______________ ________________ Mendocino Coast Hospitality Clinic _______________ ________________ Mendocino Coast Hospitality House ________________ ________________ SUDT (AOD Assessment/Treatment) ________________ ________________ Project Sanctuary (Domestic Violence) ________________ ________________ Mendocino Coast Children’s Fund ________________ ________________ Redwood Community Services (RCS) ________________ ________________ Social Services (Calfresh/Medical/GA) ________________ ________________ Fort Bragg Food Bank (Food/clothing) ________________ ________________ Coastal Street Medicine (MCHC) ________________ ________________ Mendocino Coast Clinics Inc ________________ ________________ Mendocino County Court Self Help _________________ ________________ STAFF NAME:___________________________ DATE:_____________ CRU ENROLLMENT:_____________________