ARISE Intake Form This is your first step on a journey with ARISE Native Family Advocacy. Give yourself plenty of time to complete the intake form.Allow at least 15 minutes to complete the entire form.Answer questions to the best of your ability and in your own words.Search your heart and answer as honestly as possible.All answers are private and confidential.Hit the Submit button at the end of this form.We will contact you to set up an in-person meeting. Here are some helpful tips to complete and submit the ANFA intake form: Intake Form Name * First Name Last Name Email Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Who is completing this form? Applicant Freind, relative or representative of applicant ARISE intake staff If you are completing this form on behalf of the applicant, please list your name and relationship to the applicant. Are you a member of a Native American tribe? Yes No If you answered Yes above, please list all tribal affiliations. Are you a U.S. military veteran? Yes No If you answered Yes above, list military branch and years of service. The ARISE Commitment: I am willing and able to commit to a process of discovering and applying solutions to achieve more balanced living and better household management. Yes, I commit. No, I cannot or will not commit at this time. If you answered No above, please explain why you cannot agree to the ARISE commitment ? In your own words, describe why you are applying for ARISE. What are your primary concerns regarding balanced living and better household management?. What challenges do you currently face? Please answer in your own words. Are you safe? Yes, I am safe. No, I am not safe. I am uncertain about my safety. If you answered, "No, I am not safe" or "I am uncertain about my safety," please explain why. Is everyone in your household safe? Please explain. Do you have emergency needs? Yes No If you answered Yes to emergency needs, please explain. List the names and ages of all the dependent children and adult dependents living with you or that you help to support. Have you been diagnosed with any emotional or psychological disorders? Yes No No, but I should be diagnosed. If you answered Yes above or that you should receive a mental health diagnosis, please explain. Do you think you need a current mental health evaluation? Yes No If you answered Yes to needing a mental health evaluation, please explain why. List any mental health prescriptions you are taking. Do you self-medicate with illegal or non-prescribed drugs or alcohol for mental health reasons, such as anxiety, depression, PTSD or other disorders. Yes, I self-medicate for mental health reasons. No, I do not self-medicate for mental health reasons. Please explain if you answered Yes to self-medicating for mental health reasons. Did you experience trauma as a child? Yes, I experienced childhood trauma. No, I did not experience childhood trauma. Maybe. I may have experienced childhood trauma. Please explain any actual or possible childhood trauma. Explain any actual or possible adult trauma. Have you experienced, or are you experiencing, trauma as an adult? Yes No Maybe Are you physically disabled or limited in physical abilities? Yes No Please explain any physical disabilities or limitations. List any physical health or medical prescriptions you take or should take. Please explain if you self-medicate with illegal or non-prescribed drugs or alcohol for physical health reasons, such as pain or mobility, diseases or neurological disorders. When is the last time you had a medical examination? Do you consider yourself healthy? Yes No I don't know. If you answered "No" or "I don't know," about feeling healthy, please explain why. Do you receive disability benefits for mental or emotional disorders, or physical limitations? Yes No Please list all disability benefits you receive. Do you receive any military benefits? Yes No Please list all military benefits you receive. Do you receive any tribal stipends, general assistance, commodities or other tribal benefits? Yes No Please list all tribal benefits you receive. Are you currently employed and earning income from working at a job? Yes No Please list current employer(s), employment position, and approximate weekly income. Do you have any other income sources that help to pay for rent or utilities, buy food or pay for living expenses? Yes No Sometimes I have additional income sources. Please list all other income sources that you use to manage household living expenses. Include any supplemental income sources, such as relatives and friends who pay rent. Include any income you earn as a caretaker, babysitter, cook or mechanic, for example. And include any SSDI or other supplemental income sources not mentioned previously. Do you own your own home? Yes No Do you rent the place where you are living? Yes No Is your current housing situation stable? Yes No I don't know if my current housing is stable. In your own words, explain the status of your current housing situation. How much do you pay each month to live and manage your household? To the best of your ability, list rent or mortgage, utilities and maintenance costs. What is your relationship status? Married and living with spouse Married and not living with spouse Engaged to be married Currently dating Single How many people live in your house? List each person and their relationship with you. Briefly describe how things are between you and the people who live in your household? Include relationships with kids, adults, friends and all relatives living in your household. Is there any substance abuse, alcoholism or active addiction among the people who live in your household? Yes No If you answered yes above, describe the substance abuse, alcoholism or active addiction among the people who live in your household. How are you dealing with the substance abuse and addiction in your household? Briefly explain. Do you struggle with substance abuse or addiction? Yes No Sometimes List and explain any current substance abuse or addiction challenges you face. Addictions may include gambling, codependency (relationships), sex, prescriptions, alcohol, illegal drugs, tobacco, marijuana, inhalants, and others. Do you consider your daily and weekly diet to be healthy? Yes No Briefly explain the above answer you chose about the health of your daily and weekly dietary intake. How much do you spend each week on food? Answer to the best of your knowledge. Do you exercise or participate in any physical fitness activity? Yes No Sometimes Please explain your answer about physical fitness and exercise. Do you pray or participate in any spiritual practices? Yes No Sometimes Please explain your answer about prayer and spiritual practices. Thank you!
