Step 3 Client (Self) Assessment (money saver)

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Step 3: Client (self) Assessment
Thank you for considering Le Blanc Consulting for your services. Please take the time to fill out the form bellow as it will help us to serve you better. If you are filling this form out for someone else, please answer as many questions as possible to assist with providing the best wrap around support we can since quality service is our number one priority. Please note: If there is a wait-list, once you have filled out this application you will receive a letter and a phone call informing you what number you are on our wait list. Thank you so much for your time and patience.

Step 3: Client (Self)Assessment
(Saves you money and time if you want your clients to start immediately)
Please fill out this confidential form

* Indicates required field

Accessing Health & Medical Services

Have you ever been a victim of domestic violence? *

If you answered yes to the above please indicate when was the MOST RECENT domestic violence experience *

What type of Medical Care do you need? *

Are currently seeing a Psychologist, or Therapist? *

Who is your Psychologist, Counselor or Therapist? *

Have you taking time to learn about the options available for preventing pregnancy? *

Are you or your partner on birth control? *

How often do you use recreational drugs? *

What kind of Drugs do you take? *

Do you exercise regularly? *

Are you satisfied with your current weight? *

Do you have health insurance? *

Are you immunized and are they current? *

Are you on any prescribed medication? *

What medication(s) do you take? *

Do you take your medication as prescribed and with out being prompted? *

Are you familiar with the risks associated with smoking, drinking and using drugs? *

Have you been tested for HIV/AIDS, and sexually transmitted diseases? *

Do you regularly schedule and get to medical and dental appointments independently? *

Have you found an adult health care provider? *

Who is your health care provider? *

Have you had an appointment with your health care provider? *

Do you have a dentist? *

Who is your dentist? *

Are you familiar with how to use your insurance or medical card? *

Life Domain Functioning
0= no evidence of problems
1= history, mild
2= moderate
3=severe

Has your partner or anyone currently in your life ever:

Academic History

Years of Education *

Elementry High School Some College College Graduate

What grade did you last complete? *

What is or was your favorite subject in school? *

Repeated a grade? *

If Yes, which grade? *

School *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can you read and write? *

LIVING ARRIANGEMENTS

Do you have a place to live or have you started looking for one? *

Where do you live now? *

What services do you need to help you live where you want? *

If you fell down at would someone be at your home to help pick you up? *

Where do you want to live? *

What kind of place are you looking for? *

Are living alone or can you get a place to live independently? *

Do you need help cleaning up your home? *

OVERALL INDEPENDENCE

Do you have an Identification Card? *

Do you have any savings? *

Are you contributing to the house hold income (e.g., paying rent, utilities, etc.)? *

Do you have access to the internet at home? *

Do you know how to pay bill on your own? *

Can you cook on your own? *

When was the last time you cooked something and what did you cook? *

Do you have a steady source of income? *

Do you have a reliable source of transportation? *

Do you have a car? *

Do you have a drivers license? *

Do you know how to grocery shop on your own? *

Can you take a bath or shower on your own? *

When was the last time you had a bath or shower? *

INCOME & WORKING ENVIRONMENT

EXTRA CURRICULAR ACTIVITES

What do you do for fun? *

What new things do you want to do? *

When was the last time you went out with friends or family? *

What services to you need to help you do the things you want to do? *

Can you call someone to take you out if you need to? *

What was the last movie you saw? *

Can you call someone to take you out if you need to? *

SOCIAL RELATIONSHIPS

Family History

Siblings Name (Include Step Siblings) *

First

Last

Siblings Name (Include Step Siblings) *

First

Last

Siblings Name (Include Step Siblings) *

First

Last

Sibblings Name (Include Step Siblings) *

First

Last

Is there a history of mental illness in your family? *

Who had a mental illness? *

Is there a history of drug abuse in your family? *

Who had a history of Drug Abuse? *

Age *

Income *

Income Source *

If you receive more than one please explain here *

Non-Cash Benefits *

If you receive more than one please explain which ones here *

Are you working? *

Where do you work now? *

Where do you want to work *

Do you think your school work/ work or day program assignments are at the right level for you? *

Do you attend work/class/Day program regularly? *

Are you doing well in school/work/day program? *

Where do you want to work? *

Additional Information
Is there anything else that you would like us to know?

Submit

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Open Monday - Friday (Saturday and Sunday by Appointment Only) 9am to 7pm Pacific Time. Contact us Toll Free: (800) 707-1852
Please Note: If you have questions, please feel free to contact us and we would be happy to speak with you. Le Blanc consulting reserves the right to refuse services and admission to our programs. The information presented in this website is for informational use only. It is not intended to diagnose or treat any medical condition. Please consult a health practitioner before embarking on any health protocol. Moreover, LeBlanc Consulting is not responsible for any problems, issues, or technical difficulties related to downloading or accessing any information on this website. This web site is designed for your general information only. The information presented on this website should not be construed to be formal Therapeutic Counseling sessions or advice nor the formation of a Therapist/client relationship. Furthermore, the hiring of a Professional is an important decision and should not be based solely upon any form of advertisements. Before you decide to hire, please feel free to review our degrees and certification by contacting us for more information about our qualifications and experience. Intellectual Property & Copyright Material Warning: All images are on this website copyright to their respective owners/photographers, no copyright infringement intended. Some of the material and documents available for your view is copyrighted and protected by applicable state and federal copyright laws. LeBlanc Consulting respects the intellectual property of others, and we ask our users to do the same.You are not authorized and may not reproduce, download, post, modify, distribute, or reproduce in any way copyrighted or other proprietary materials that are stored in this database without obtaining the prior written consent of the copyright owner of such materials. We may, in appropriate circumstances and at our discretion, deny access to a site or service or disable and/or terminate the accounts of any user who is alleged to have infringed the intellectual property or proprietary rights of LeBlanc Consulting or another. The use, reproduction, downloading, or distribution of copyrighted materials and works may subject you to applicable penalties and damages under state and federal copyright laws. You are granted public access to such copyrighted works in our database for examination and inspection purposes only. Although every reasonable effort has been made to ensure the accuracy of the public information data and graphic representations, LeBlanc Consulting cannot and shall not be responsible for consequences resulting from any omissions or errors contained herein. LeBlanc Consulting assumes no liability whatsoever associated with the use or misuse of this data. Mandated Reporter Notice: All Consultants, Caregivers and staff affiliated with Le Blanc Consulting are considered Mandated Reporters.California Law, under section WIC 15630(a) of the Welfare & Institution Code provides for mandatory reporting of physical abuse, neglect, self neglect, sexual abuse, mental suffering, financial abuse, isolation, abandonment or abduction of a dependent adult when:1) The victim reports abuse has occurred or has knowledge of abuse. 2) You observe the incident. 3) when an injury or condition reasonably leads one to suspect that abuse has occurred. Any signs of abuse should be reported to Adult Protective Services. Protective Service Numbers: Community Care Licensing Complaints about Care Facilities (844)538-8766. National Domestic Violence Hotline: (800) 799-SAFE (7233)

Step 3: Client (Self)Assessment (Saves you money and time if you want your clients to start immediately)Please fill out this confidential form

Step 3: Client (Self)Assessment
(Saves you money and time if you want your clients to start immediately)
Please fill out this confidential form