Intake Screening

(This information will be kept confidential in the strictest manner. It will only used for the purpose intended. Please note, our facilities are located in Southern California. Find a shelter in your area here.)

Time for Change Foundation
P.O. Box 25040
San Bernardino, CA 92406

First Name

Last Name

Address

County

Age

D.O.B.

Phone

Have you ever been incarcerated?

Months:

Years

What were your charges?

Are you recovering from drugs & alcohol?

Drug of Choice:

How long have you been clean & sober?

Are you currently in a recovery program?

Which program are you in or have you been in during the last 12 months?

What are your goals?

What have you done to accomplish these goals in the last 2 weeks? 30 days?

Do you have children?

How many?

Ages/Gender

Do you have an income/source?

Is it Weekly, Bi-Weekly or Monthly?

What is your present living situation?

How did you hear about our program?

Last occupation?

Last time you worked? (Full time/part time?)

Have you been a victim/perpetrator of domestic violence?

Do you want counseling?

Have you been diagnosed with a mental illness?

If so, are you taking medication for your illness(es)? Yes/No

If no, why not?

Can you lawfully be around children? *

Yes

No

Can you emotionally tolerate being around children?

How do you get along with people?

What are you housekeeping habits?

Proof of CA ID

Proof of Social Security Card

E-mail *