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* 1. Who is completing this form?

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* 2. How old are you?

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* 3. How did you hear about us?

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* 4. Where do you live?

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* 5. If you are Homeless, where did your homelessness begin?

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* 6. What year did your Homelessness begin?

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* 7. What Resources do you need help with? (check all that apply)

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* 8. Do you or someone in your family need help with Advocacy for community resources (circle all that apply):

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* 9. Highest level of education?

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* 10. What is your Employment status:

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* 11. If Employed, how long have you worked at the company?

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* 12. What is your household income?

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* 13. Do you have any previous evictions? If so, what year(s)?

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* 14. Do you have short term goals/needs, if so, list them?

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* 15. Do you have long term goals/needs, if so, list them?

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* 16. Do you have Health Insurance?

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* 17. Who is your Health Insurance carrier?

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* 18. How many people are in your household?

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* 19. Do you have children? 

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* 20. Are you currently using any method of birth control?

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* 21. What are your reasons for not using any method of birth control?

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* 22. Would you consider using any form of birth control in the future?

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* 23. Are you working with any other Case Managers in the community? (Ex: DFACS, Housing Case Manager, Etc.)

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* 24. Have you ever been convicted of a Crime? 

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* 25. Are you currently on Probation or Parole?

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* 26. Some supportive housing programs require you to complete a drug test as part of their program? Will you be able to pass a drug test?

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* 27. Have you ever been diagnosed with a Mental Health or Substanse use disorder?

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* 28. Are you currently a victim of domestic violence and/or fleeing from domestic violence?

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* 29. Have you or anyone in your household experienced any traumatic events since you have been homeless?

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* 30. To receive Advocacy services, BWell Outreach program requires a mental health assessment and evaluation from one of our partnered licensed providers, however, if you qualify for therapeutic services, do you agree to participate in counseling?

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* 31. On a scale of 1-10 rate your happiness with your current situation(1 being not happy and 10 being very happy)

1 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 32.

                                            ACE STUDY 
There are 10 types of childhood trauma measured in the ACE Study. Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment.

The most important thing to remember is that the ACE score is meant as a guideline: If you experienced other types of toxic stress over months or years, then those would likely increase your risk of health consequences.

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* 33. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

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* 34. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? 

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* 35. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?

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* 36. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?

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* 37. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

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* 38. Were your parents ever separated or divorced?

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* 39. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

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* 40. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

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* 41. Was a household member depressed or mentally ill, or did a household member attempt suicide?

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* 42. Did a household member go to prison?

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* 43. Thank you for participating in the BWR survey. All information is confidential and will be used solely for the purpose of resource coordination. This survey will not be used to exploit and/or misrepresent you, the participant and/or the participant’s needs who complete the survey. Each participant will be connected and assigned to resources according to their needs assessment and treated with dignity, admiration, and respect during the collaboration process. By signing this you are giving BWR permission to use and share information with third party providers to provide a service and resource coordination. I certify that I have read the above information. Any questions concerning these policies have been discussed.

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