Intaketommy2025-05-08T05:26:44+00:00 Brakin Out Inc. Intake Form Section 1: Participant Information Full Name: Preferred Name: Date of Birth: Age: Gender Identity: Preferred Pronouns: Phone Number: Email Address: Address: Emergency Contact Name: Emergency Contact Relationship: Emergency Contact Phone Number: Section 2: Housing and Living Situation Current Living Situation: Home with familyTransitional housingHomelessGroup homeShelterIncarceratedOther Is your current housing temporary or long-term? Do you feel safe? YesNo Section 3: Legal & Justice Involvement Current Status: On probationOn paroleAwaiting trialNone Most recent legal issue (optional): Probation/Parole Officer Contact: Court-mandated to attend? YesNo Section 4: Personal Goals & Readiness What do you hope to gain from Brakin Out? Where do you see yourself in 6 months? What’s holding you back? Motivation to change (1–5): Section 5: Mental Health & Substance Use Received mental health servicesCurrently in therapyStruggled with substance useCurrently in recovery Section 6: Needs Assessment Select all that apply: MentorshipEmotional supportJob skills / trainingGED / School enrollmentHousing assistanceLGBTQ+ supportTransportation assistanceFood/clothingChildcareLegal helpFamily reunificationOther Section 7: Program Interests Second Chance ProgramLGBTQ+ Support ProgramYouth EmpowermentCreative Healing (Art, Music, Expression)Leadership DevelopmentCommunity Impact Projects Section 8: Self-Assessment Scale (1 = Strongly Disagree, 5 = Strongly Agree) I feel ready to make changes. 12345 I have a support system.12345 I feel safe where I live.12345 I believe in my ability to succeed.12345 I have unmet needs affecting progress.12345 Section 9: Additional Information Upload Documents (optional): Preferred Location: Dallas, TXMobile, ALVirtual/Online OnlyNo preference Section 10: Photo & Media Release Yes, I give permissionNo, I do not give permission Signature: Date: Section 11: Consent & Signature Participant Signature: Date: Parent/Guardian Signature (if under 18): I confirm that all the information provided is accurate...
