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Abeona and Halcyon (STRTP’s)
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HOHTHP+NMD Pre Placement Appraisal
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HOHTHP+NMD
Pre Placement Appraisal
Participant’s Name
Date
MM slash DD slash YYYY
Age
Gender
DOB
MM slash DD slash YYYY
SSN
Current Address or Placement
Social Worker/Probation Officer/Other
Contact Information: Phone
Email
Referring County
Why are you interested in Haven of Hope’s THP+NMD Program?
What are your future goals and interests?
What are some of your greatest challenges/areas you may need support with?
Financial Information
Current Accounts
I have a savings account
Yes
No
Name of Bank
Current Balance
I have a checking account
Yes
No
Name of Bank
Current Balance
I have a credit card
Yes
No
Name of Card
Current Balance
Briefly describe any outstanding debt
Work History
From (mo./yr):
to
hourly rate
Average hours per week
Employer
Supervisor
Address
Phone
Job Title
Duties
From (mo./yr):
to
hourly rate
Average hours per week
Employer
Supervisor
Address
Phone
Job Title
Duties
Have you ever been fired from a job: yes/no
Yes
No
Third Choice
(If yes, please explain)
Education Information
Are you currently attending school/training courses?
Name
Last school attended
Location
Date
MM slash DD slash YYYY
Highest grade completed
Please describe your educational goals
Legal Information
Have you ever been arrested (If yes, please answer below)
Yes
No
Date
MM slash DD slash YYYY
Offense
Briefly describe incident
Medical Information
Please describe any medical/health issues
If taking medications please list all medications/dosage
Current Physician
Phone
Counseling History
Are you currently participating in counseling services?
Yes
No
If yes, please provide Name/Phone
Have you participated in counseling services in the past?
Yes
No
If yes, please provide Name/Phone
Would you be interested/need assistance in pursuing counseling services?
Yes
No
High Risk Behaviors/Challenges
Alcohol
Yes
No
Drugs
Yes
No
Weapons
Yes
No
Gang history
Yes
No
Danger to self
Yes
No
Fire setting
Yes
No
Stealing
Yes
No
Awoling
Yes
No
Danger to others
Yes
No
Property damage
Yes
No
Hx of sexual abuse
Yes
No
Hx of physical abuse
Yes
No
If you answered yes to any of the above, please explain when you last engaged in such behaviors
Please describe your coping skills
How do you deal with peer pressure?
What would be your goals in a THP+NMD program?
Please describe your best independent skills and any training you may have had towards successful independence
Please describe your skills/strengths
Please describe your interests/recreational activities
Please identify significant family/friends in your life
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
Most recent caregiver name/phone
*We will need to speak with most recent caregivers regarding independent living skills and recent behaviors.
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