Name:                                                                               

Phone #:

Date:

Describe Your Mental Illness - Include Symptoms and History:

Does Your Current Medication Reduce the Symptoms of Your Mental Illness?   

 Yes      No

How Many Times Have You Been in the Hospital and/or Treatment Because of Your Mental Illness?

How Many Times Have You Tried to Commit Suicide?

Describe Your Attempt(s):

Describe Your Alcohol and/or Drug History:

How Much Sobriety Do You Currently Have?

How Old Were You the First Time You Used?

Do You Attend 12 Step Meetings Regularly?  Yes    No

Do You Have a Sponsor?  Yes     No

How Many Times Have You Been In Jail?

Describe All Past Criminal Charges and Dates:

Are You Employed?   Yes     No

If Yes, Where and Work Schedule:

Who Makes Up Your Support System?

Do You Believe You Can Recover from Your Mental Illness?  

 Yes     No

What Kind of Help Do You Need from Transition House, Inc., in Your Recovery Process?

CHECK THE FOLLOWING AREAS IN WHICH YOU NEED HELP:

□  Community Housing

□  Securing Income

□  Medication Management

□  Socialization

□  Anger Management

□  Self-Esteem

□  Community Living Skills

□  Budgeting

□  Communication

□  Mental Health  Recovery

□  Assertiveness

□  Maintaining Sobriety

Below is a list of problems which many people have---problems relating to health, work, family, temperament, and so on.  Please read through the list and check those statements that represent your problems.

□   Lacking self-confidence

□   Feeling I am too different

□   Not being really smart enough

□   Feeling no one cares for me

□   In trouble with the law

□   Feeling life is not worthwhile

□   Confused in my religious beliefs

□   Trying to forget an unpleasant experience

□   Getting into debt

□   Finding sexual behavior hard to control

□   Lacking motivation

□   Needing an income

□   Being easily led by others

□   Not knowing how to look for a job

□   Feeling ill at ease with other people

□   Not knowing my vocational abilities

□   Not really having any friends

□   Constantly worrying

□   Getting into arguments or fights

□   Too emotional

□   Speaking or acting without thinking

□   Feeling inferior

□   Being stubborn

□   Having difficulty in making decisions

□   Being jealous

□   Feeling I am a failure

□   Being treated unfairly

□   Drug Use

□   Feeling forgotten by my family

□   Drink too much

□   Self-mutilation

□   Unsure of sexual orientation

□   Bothered by thoughts of suicide

□   Feeling blue and moody

*This facility does not permit discrimination because of age, gender, race, religion, color, creed, sexual orientation, place of national origin, disability, inability to pay.