Triage Tool (062718)

Triage Tool

We are here to help you set and achieve your GOALS! As a first step we want to be sure we understand where you are coming from. This form will help us connect you with services and activities of interest to you. Leave anything blank that you do not want to answer. Thanks for answering these questions!
Name
Date

MonthDayYear
1. Why did you come in today? What are you looking for?

0/32
2. What should I know about you?

0/32
3. Are you currently employed?

YesNo
If so, how many hours a week do you work?
If no, would you like more information about our employment services?

YesNo
4. Do you have a high school diploma or GED?

YesNo
5. Are you currently attending school? (if so please fill in below)

YesNo
Class Schedule (please select day(s) that you attend):

MTWThFSa
Name of school/location
6. Can you think of anything that is preventing you from participating in work and/or training related activities?

YesNo
If Yes, what comes to mind?
7. Are you a current/former foster youth between the ages of 16-24?

YesNo
8. Do you feel safe and stable right now?

YesNo
If no, why not?
9. Have you ever applied, or are you now in the process of applying for SSI/SSP/SDI?

YesNo
If yes, date applied:

MonthDayYear
mm/dd/yyyy
Outcome:

DeniedApprovedAppealingAwaiting Decision
10. Services requested

YesNo
10. Would you like more information about services related to anything below?

CounselingHelp with addictions/substance abuseHelp with violence at homeAnger managementHousing assistance
Signature
Should be Empty: