Intake Assessment

NOTE: It is safe to submit your information as this is a secure site and is fully protected, hence our https stamp.

Those wishing to not complete our online application submission process may print our paper Intake Application and email it to drduru@thewiseorg.org.

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Privacy Policy: We do not share, sell, or rent your information with any third party outside of our organization. We understand the importance of privacy and are committed to maintaining the confidentiality of your personally identifiable information and/or medical history.

Disclaimer: Applicants not qualifying for our program are automatically referred to one of our many resource-partners to receive pre-support services.

Instructions: Please provide the following information to be used in our assessment to determine if you’re fit for our Becoming WISE mental development program.

    Full Name Full Address Age Date of Birth US Citizen YesNo Phone 1 Phone 2 Email Address In case of emergency, who may we contact on your behalf?
    Full Name: Relationship: Address: Phone: Full Name: Relationship: Address: Phone:
    *CURRENT STATUS AND HISTORY*
    Are you married? YesNo If yes, spouse name?
    Do you have children? YesNo If yes, how many? Age(s)?
    Living Arrangements? RentLiving with othersShelterHomeless
    Employed? YesNoIf yes, Full TimePart Time
    Employer Name: Length of Employment:
    Highest Level of Education GED/High SchoolSome CollegeCollege DegreeGraduate SchoolOther
    Do you consume alcoholic beverages ? YesNo
    If yes, how often? 1 to 3 times per week4 to 10 times per week10+ times per week
    Do you smoke? YesNo If yes, have you ever tried to quit? YesNo
    Have you in the past, or currently: Used, Abused, Experimented with illegal drugs? YesNo
    If yes, briefly explain:

    Do you suffer from anxiety?YesNo
    If yes, how often? 1 to 3 times per week4 to 10 times per week10+ times per week3 to 5 times per month

    Do you suffer from depression or experience depressive moods?
    If yes, how often 1 to 3 times per week4 to 10 times per week10+ times per week3 to 5 times per month

    Are you having suicidal thoughts? YesNo
    1 to 3 times per week4 to 10 times per week10+ times per week3 to 5 times per month
    Have you ever attempted suicide? YesNo If yes, describe briefly and indicate dates:

    Have you ever had a psychiatric hospitalization? YesNo If yes, describe briefly and indicate dates:

    Are you currently seeing a counselor, psychiatrist, therapist, psychotherapist, psychologist? YesNo
    If yes, check all that applycounselorpsychiatristtherapistpsychotherapistpsychologist

    Are you currently taking medication prescribed by a licensed physician? YesNo
    If yes, please list medication name:

    Have you ever been professionally diagnosed with any chronic illness, disability, medical conditions and/or impairments? YesNo
    If yes, please list date and name of diagnosis:

    Have you ever received or given abuse? YesNo
    Given
    If yes, check all that apply PhysicalEmotionalSexualNeglectOther
    Received
    If yes, check all that apply PhysicalEmotionalSexualNeglectOther

    (Post Traumatic Stress Syndrome is flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about an event you witnessed and/or experienced.)
    Do you suffer from PTSD? YesNo
    Have you sought treatment? YesNo
    If yes, describe briefly your PTSD:
    Have you ever been arrested? YesNo If yes, how many times
    Have you ever been convicted of a crime? YesNo
    If yes, describe briefly indicate dates:
    Are you currently on Probation or Parole? YesNo
    If yes, describe briefly indicate dates:

    Check Your TOP 5 Immediate Needs
    SafetyFoodObtaining Vital RecordsHousingNew Job
    TransportationClothingInvestment PlanningMental Health ConcernsCareer Planning
    Credit RepairPhysical Health ConcernsCollege (New/Returning)Banking (Opening Checking/Savings Acct
    Vocational TrainingContinuing EducationHealth Insurance
    *HOW CAN WE HELP YOU*
    What brought you to The W.I.S.E. Org?


    What do you hope to gain if you are selected for The W.I.S.E. Org program(s)?


    Is there anything that would be a hindrance in completing your program/goals if you are selected? ?



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    APPLICANT SIGNATUREDATE:
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