Pre-Screen/Referral Form

Group Residential Housing (GRH) Program

To be completed by Client Representative ONLY. To make a referral to our Outpatient Treatment Program, please fax a

Rule 25 Assessment to 612-594-2030, ATTN: Intake.

Client’s Name: __________________________________ Client’s DOB: _________________

Client’s Contact Number: ____________________________ Email: ________________________

Source of Income: _____________________ Monthly Amount: ______________

Referent’s Name: _________________________________ Title: _______________________

Contact Number: ____________________________ Email: ________________________

Referent’s Agency/Organization: _____________________________________________ If you do not receive an email confirming we received this referral within three business days, please email intake@houseofcharity.org to ensure we received it.

Vulnerability Assessment Questions All questions are based on a 1-5 point scale, 1 being no evidence of vulnerability in the area outlined and 5 being

evidence of strong vulnerability rating in the area outlined. Housing referrals will be scored and placed accordingly on our current GRH wait-list. The Pre-Screen/Referral Form gauges the clients need for housing, and

determines if House of Charity programming is suitable for the client. Survival Skills – Vulnerability, safety, dependency on others, judgment

How would you rate your clients’ survival skills? 1-No Evidence of Vulnerability (Needs no prompting regarding safe behavior)

2-Evidence of Mild Vulnerability (Needs some assistance in recognizing unsafe behaviors)

3- Evidence of Moderate Vulnerability (Often in dangerous situations, being taken advantage of)

4-Evidence of High Vulnerability (Lacks “street smarts”, childlike or helpless demeanor)

5-Evidence of Severe Vulnerability (Easily draws predators, vulnerable to exploitation)

SCORE: _____

Basic Needs – Ability to obtain/maintain food, clothing, hygiene, etc.

How would you rate your clients’ ability to meet their own basic needs? 1-No Trouble Meeting Needs (Generally able to use services; food, hygiene, clothing)

2-Mild Difficulty Meeting Needs (Some trouble staying on top of basic needs)

3- Moderate Difficulty Meeting Needs (Occasional attention to needs, but able with assistance)

4-High Difficulty Meeting Needs (Doesn’t wash regularly, low insight regarding needs)

5-Severe Difficulty Meeting Needs (Unable to meet needs on own; food, hygiene, clothing)

SCORE: _____

Indicated Mortality Risks Please tell me which of the following apply to your client: __ Aged 60 or older __ Cirrhosis of the liver __ More than 3 ER visits in 3 last 3 months

__ Diabetes __ Renal Disease __ More than 3 hospitalizations in 12 months __ Heart Disease __ Tri-Mobility: Psychiatric, Substance Abuse, & Chronic Medical Condition 1-Has none of the 8 identified risk factors

2-Has 1 of the identified risk factors

3- Has 2 of the identified risk factors

4-Has 3 of the identified risk factors

5-Has 4+ of the identified risk factors

SCORE: _____

Medical Risks – Medical conditions that impact a person’s ability to function How would you rate your clients’ current Medical Risks? 1-No Impairment (Appears well, not medical complaints)

2-Minor or Temporary Health Problems (Cast, splint, recovering from minor surgery, acute medical problems)

3- Significant Physical or Medical Condition (Stable Diabetes, Hepatitis C., Cancer in remission, HIV being treated, or Seizure disorder being managed by doctor or over 60 and does not access medical attention)

4-Chronic Medical Condition (Poorly managed Diabetes, Hepatitis C, HIV, Liver failure, Pregnancy, Cancer, Incontinence, hospitalized in the last 3 months, can’t name last seen doctor, or not medication compliant)

5-Totally Neglectful of Physical Health (Serious health condition, Untreated AIDS, Blind, Deaf, Mute, Terminal Illness that is worsening, obvious physical problems not being treated)

SCORE: _____

Organization/Orientation – Thinking, developmental disability, awareness, cognitive abilities

How would you rate your clients Organization/Orientation? 1-No Impairment (Good attention span, adequate self-care)

2-Mild Impairment (Occasional difficulty staying organized, mild developmental disability)

3- Moderate Impairment (Appearance sometimes disorganized, moderate memory or developmental disability)

4-High Impairment (Disorganized or disorientated, poor awareness of surroundings)

5-Severe Impairment (Highly confused, evidence of serious developmental disability, very poor memory)

SCORE: _____

Mental Health – MH services, spectrum of MH symptoms & how these impair functioning

How would you rate your clients’ Mental Health status? 1-No Mental Health Issues

2-Mild Mental Health Issues (Situational Depression)

3- Moderate Mental Health Issues (Reports diagnosis, reports having services in place and taking meds)

4-High Mental Health Issues (Reports diagnosis, not interested in services, not med compliant, low insight)

5-Severe Mental Health Needs (No connection to services, extreme symptoms impairs functioning, paranoia, manic mood, extreme depression, talking to self)

SCORE: _____

Substance Abuse – Issues related to substance use, services, spectrum of substance and how use impairs functioning

How would you rate your clients current Substance Use? 1-No/Non-Problematic Substance Use (No negative impact on level of functioning)

2-Mild Substance Use (Sporadic Use not obviously affecting functioning, still able to meet basic needs)

3- Moderate Substance Use (90-180 days in recovery, use affecting ability to care for basic needs, binge user)

4-High Substance Use (First 90 days of recovery, high relapse potential, use is clearly affecting self-care)

5-Severe Substance Use (Active addiction with little/no interest in CD involvement, severe symptoms of substance use and mental illness, obvious deterioration in functioning)

SCORE: _____

Communication – Ability to communicate with others, initiate conversations

How would you rate your clients’ Communication barriers? 1-No Communication Barrier (Strong and organized ability, no language barriers)

2-Mild Communication Barrier (Has occasional trouble communicating, language barrier, occasionally reacts inappropriate when under stress)

3- Moderate Communication Barrier (Some disorganized thoughts, poor attention span, very limited English)

4-High Level Communication Barrier (Hearing impairment, doesn’t speak English, unwilling/able to communicate with staff)

5-Severe Communication Barrier (Mute, fragmented speech, refuses to talk to staff, may leave to avoid talking)

SCORE: _____

Social Behaviors – Ability to tolerate people & conversations, ability to advocate for self, cooperation, etc.

How would you rate your clients’ Social Behaviors? 1-Predatory Behaviors and/or No Problem Advocating for Self (History of predatory behaviors, targets vulnerable adults, more than adequately advocates for own needs)

2-Mildly Problematic Social Behaviors (“Gets Along”, tolerates input & responds with minimal problems)

3- Moderately Problematic Social Behaviors (Difficulty coping with stress, at times has angry outburst or non-cooperative with staff)

4-Highly Problematic Social Behaviors (Often has difficulty coping with stress, withdrawn and isolates, negative behaviors often interferes with others surroundings, yells, screams or talks to self)

5-Severly Problematic Social Behaviors (Responds in anger, profane, obscene or menacing ways, significantly impaired to deal with stress, no apparent social network)

SCORE: _____

Homelessness – Length of time homeless How would you rate your clients’ current length of homelessness? 1-Newly Homeless (Homeless for less than 1 month, new to the area)

2-Moderate Homelessness (Has been homeless for 1-12 months, few prospects for housing at present)

3- Chronically Homeless (Has been homeless for 1 year + or has had at least 4 episodes of homelessness within the last 3 years; may have no options dues to history)

SCORE: _____

Please provide any additional information that will help us to assess your client’s need for House of Charity’s services. This can include details about information given above or additional information that has not been covered:

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Please fax back to 612-594-2030, ATTN: Intake. Your client will be scored and placed on the House of Charity GRH Wait-list.