Do you use any recreational drugs? How often? Are you currently in treatment? Provider name Address/location Do you feel you need to be referred to a substance abuse provider for an evaluation? Challenges: Domestic Issues Do you feel safe in your home? Are there issues with domestic violence in your current relationship? Are you aware of resources for victims of domestic violence in the area? Would you want a referral? Challenges: Income/Budget Name of Employer Address Phone Type of Work How long? Income $ Are you receiving unemployment If yes, how much do you $ compensation? receive weekly? If unemployed when was the last time you Reason you left your job? worked? Have you been seeking employment? Full time or Part time? If unable to work have you applied for Social Security? If yes, are you receiving Social Security income? If no, how many have you Have you appealed the Are you waiting been denied? SSA decision? for an appeal Date of the last denial? hearing? Challenges:
Do you use any recreational drugs? How often? Are you currently in treatment? Provider name Address/location Do you feel you need to be referred to a substance abuse provider for an evaluation? Challenges: Domestic Issues Do you feel safe in your home? Are there issues with domestic violence in your current relationship? Are you aware of resources for victims of domestic violence in the area? Would you want a referral? Challenges: Income/Budget Name of Employer Address Phone Type of Work How long? Income $ Are you receiving unemployment compensation? If yes, how much do you receive weekly? $ If unemployed when was the last time you worked? Reason you left your job? Have you been seeking employment? Full time or Part time? If unable to work have you applied for Social Security? If yes, are you receiving Social Security income? If no, how many have you been denied? Date of the last denial? Have you appealed the SSA decision? Are you waiting for an appeal hearing? Challenges: