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Initial Intake Form
Intake Date
Age
Referring Agency
Referring Person
Are you Pregnant?
-
No
Yes
Expected Due Date
Marital Status
-
External
Internal
First Child Name
First Child Age
Second Child Name
Second Child Age
Third Child Name
Third Child Age
Fourth Child Name
Fourth Child Age
Ethnicity
-
American Indian/Alaskan Native
Asian
Black/African American
Hispanic
Latino
Middle Eastern/North African
Multiracial
Native Hawaiian/Pacific Islander
Other
White
Current Living Address
Current or Past Shelter
Income
SSI $
Child Support $
FoodShare $
Issuance Date
W-2
-
No
Yes
Housing Voucher/Assistance $
Other $
Car
Do you own a car?
-
No
Yes
Make
Model
Year
Color
Education
Highest Level of Education
Some College/University
2-Year College Completed
4-Year College Completed
Completed University
Post-Graduate Degree
Last School attended
Phone
Open Child Protective Service Case?
-
No
Yes
Worker
Agency
Open/Pending Criminal Cases?
-
No
Yes
State(s)
Domestic Violence
Are you in a violent relationship?
-
No
Yes
Are you fleeing or have you ever fled a violent relationship?
-
No
Yes
Last Incident of Domestic Violence
Medical Information
Therapist
-
No
Yes
Diagnosis
-
No
Yes
Name of Diagnosis
Medications
Have you ever been hospitalized? If Yes, how long & explain?
Are you open to seeing a therapist? If no, why?
Additional Information
Additional Important Information
Please review the expectations of our program:
In order to progress successfully through the program all transitional housing rules, guidelines and dailyroutines must be followed. Nia Imani staff has the right to terminate participants who are not incompliance with the following guidelines:
▪ No alcohol or drug usage while in the program
▪ No weapons- guns, knives, etc.
▪ During group and scheduled meetings, there is no cell phone use
▪ No smoking or vaping in the units except in designated areas outside of the building.
▪ No fighting or arguing on premises or in the building
▪ Visitors are allowed on designated weekends ONLY in dining room and living room areas
▪ No overnights (your children are an exception)
▪ 11pm curfew is for those who earn it and does not apply to those on probation, in-house restrictions,or quarantine) The curfew during probationary period (first 90 days) is 5pm daily.
▪ No keys to unit until after the scheduled 90-day probationary period and review with staff
▪ Do not let anyone into the building for any reason
▪ Expected to attend Group Sessions as scheduled Monday-Friday at 5:30pm (and occasional weekends)
▪ No 2nd or 3rd shift employment
▪ Assigned chores around building- including maintaining a clean unit at all times
▪ Any violation committed; keys must be turned into staff
▪ Mandatory random drug testing
▪ No burning of incense in the units
▪ No visiting in other Participant’s units
▪ No verbal or physical abuse of children
▪ A fee will be charged for any damage to the building, unit, furniture, or reckless plumbing costs
▪ Program fees and utilities must be paid by the third of every month. If late without approval from theExecutive Director, a delinquent payment fee of 3 dollars will be charged for each day late. Proof ofincome must be provided to participate in this program
Do you understand the expectations of our program?
*
Intake Date
Age
Referring Agency
Referring Person
Are you Pregnant?
Expected Due Date
Marital Status
First Child Name
First Child Age
Second Child Name
Second Child Age
Third Child Name
Third Child Age
Fourth Child Name
Fourth Child Age
Ethnicity
Current Living Address
Current or Past Shelter
Income
SSI $
Child Support $
FoodShare $
Issuance Date
W-2
Housing Voucher/Assistance $
Other $
Car
Do you own a car?
Make
Model
Year
Color
Education
Highest Level of Education
Last School attended
Phone
Open Child Protective Service Case?
Worker
Agency
Open/Pending Criminal Cases?
State(s)
Domestic Violence
Are you in a violent relationship?
Are you fleeing or have you ever fled a violent relationship?
Last Incident of Domestic Violence
Medical Information
Therapist
Diagnosis
Name of Diagnosis
Medications
Have you ever been hospitalized? If Yes, how long & explain?
Are you open to seeing a therapist? If no, why?
Additional Information
Additional Important Information
Please review the expectations of our program:
In order to progress successfully through the program all transitional housing rules, guidelines and dailyroutines must be followed. Nia Imani staff has the right to terminate participants who are not incompliance with the following guidelines:
▪ No alcohol or drug usage while in the program
▪ No weapons- guns, knives, etc.
▪ During group and scheduled meetings, there is no cell phone use
▪ No smoking or vaping in the units except in designated areas outside of the building.
▪ No fighting or arguing on premises or in the building
▪ Visitors are allowed on designated weekends ONLY in dining room and living room areas
▪ No overnights (your children are an exception)
▪ 11pm curfew is for those who earn it and does not apply to those on probation, in-house restrictions,or quarantine) The curfew during probationary period (first 90 days) is 5pm daily.
▪ No keys to unit until after the scheduled 90-day probationary period and review with staff
▪ Do not let anyone into the building for any reason
▪ Expected to attend Group Sessions as scheduled Monday-Friday at 5:30pm (and occasional weekends)
▪ No 2nd or 3rd shift employment
▪ Assigned chores around building- including maintaining a clean unit at all times
▪ Any violation committed; keys must be turned into staff
▪ Mandatory random drug testing
▪ No burning of incense in the units
▪ No visiting in other Participant’s units
▪ No verbal or physical abuse of children
▪ A fee will be charged for any damage to the building, unit, furniture, or reckless plumbing costs
▪ Program fees and utilities must be paid by the third of every month. If late without approval from theExecutive Director, a delinquent payment fee of 3 dollars will be charged for each day late. Proof ofincome must be provided to participate in this program
Do you understand the expectations of our program?
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