Dmi Assessment

283 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
283
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
2
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Dmi Assessment

  1. 1. Keeping Our Neighborhoods Safe Assessment<br />Name:________________________________________________Alias:_____________________________________<br />Address:_____________________________________________________________________________________________<br />Date of Birth:_________Age:___Contact number:__________________(h)_________________________(c)<br />Family<br />Who are the significant people in your life? ______________________________________________________________<br />______________________________________________________________________________________________<br />Natural/Step mother’s name _____________________________________ Living or Deceased? _______<br />Natural/Step father’s name ______________________________________Living or Deceased? _______<br />Children (names and ages):______________________________________________________________________________<br />Is parenting difficult for you? Y/N<br />Who lives in your household? (names and relationship to you)<br />______________________________________________________________________________________________<br />______________________________________________________________________________________________<br />______________________________________________________________________________________________<br />Goal(s):_____________________________________________________________________________________________<br />Educational Information<br />Are you currently in an educational program? Y/NDescribe _______________________________________________<br />Last grade attended __________School/s attended _____________________________________________________<br />Average grades received _________Did you like or dislike school?___________________<br />Favorite subject ____________________________Least favorite subject _____________________________________<br />Difficulties associated with school ________________________________________________________________________ <br />____________________________________________________________________________________________________<br />Goal(s): _____________________________________________________________________________________________<br />Employment history<br />Are you currently employed? Y/NFull-time [ ] Part-time [ ]How long have you worked there?______________<br />Company name:________________________________________Do you have a valid driver’s license? Y/N<br />Do you have a Social Security Card? Y/N Do you have reliable transportation? Y/N<br />How long have you been unemployed? _____________________________<br />Have you ever been in the military? Y/NRank/When ___________________________________________________<br />What type of work have you done in the past?_______________________________________________________________<br />What type of work do you like to do?______________________________________________________________________<br />Do you have any trades or special skills?___________________________________________________________________<br />What do you think your strengths are?_____________________________________________________________________<br />Goal(s): ____________________________________________________________________________________________<br />___________________________________________________________________________________________________<br />Financial Status<br />Able to meet basic needs? Y/N Difficulties: ______________________________________________________________<br />Leisure activities<br />Favorite things to do? __________________________________________________________________________________<br />Difficulties: __________________________________________________________________________________________<br />Goal(s): _____________________________________________________________________________________________<br />Religion<br />Religion _______________________Describe the role of religion/spirituality in your life: _________________________<br />____________________________________________________________________________________________________<br />Domestic Violence<br />Cite incidents: ________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________<br />Criminal History<br />Date: __________Arrests: __________Outcome: ____________________________________________________<br />Date: __________Arrests: __________Outcome: ____________________________________________________<br />Date: __________Arrests: __________Outcome: ____________________________________________________<br />Date: __________Arrests: __________Outcome: ____________________________________________________<br />Date: __________Arrests: __________Outcome: ___________________________________________________<br />Substance Abuse<br />List all drugs you have used. ______________________________________________________________________<br />___________________________________________________________________________________________<br />___________________________________________________________________________________________<br />Do you think you have a substance abuse problem? Y/N<br />Alcohol:FirstLast Frequency __________FirstLast Frequency<br />__________FirstLast Frequency__________FirstLast Frequency<br />__________FirstLast Frequency__________FirstLast Frequency<br />Have you ever been treated for substance abuse? Y/NWhen/Where?__________________________________________<br />Is there a history of substance abuse in your family? Y/NDescribe ________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________<br />Are there members or friends who say you have a substance abuse problem? Y/N<br />What are the problems associated with chemical dependency? (DUI, accidents, legal, suspensions, etc.)<br />Health<br />Any past medical problems?_____________________________________________________________________________<br />Status of general health _________________________________ Where do they get health care services?______________<br />Date of last physical? _____________Any current physical complaints? ________________________________________<br />Hospitalizations (when/why/where) _______________________________________________________________________ ____________________________________________________________________________________________________<br />Current difficulties? ____________________________________________________________________________________<br />Goal(s): _____________________________________________________________________________________________<br />Mental Health<br />Is there a history of mental illness in your family?____________________________________________________________<br />Have you ever been treated for a mental illness? Y/NWhat/Where?___________________________________________<br />Treatment services (counseling, prescriptions, etc.) ___________________________________________________________<br />What do you see as problems in your life? __________________________________________________________________<br />How bad do you think they are? __________________________________________________________________________<br />Strengths? ___________________________________________________________________________________________<br />Weaknesses? _________________________________________________________________________________________<br />

×