Criminal History:

Have you been charged with or convicted of murder?
YesNo

Have you been charged with or convicted of attempted murder?
YesNo

Have you been charged with or convicted of assault with a deadly weapon or aggravated assault/battery?
YesNo

Do you have 2 or more domestic violence charges or convictions?
YesNo

Have you been charged with or convicted of lewd and lascivious acts?
YesNo

Do you have to register as a sex offender?
YesNo

Do you have any charges or convictions against children or elderly individuals?
YesNo

Mental Health:

Do you currently, or have you ever had a diagnosis of schizophrenia/paranoid schizophrenia?
YesNo

Do you currently, or have you ever had a diagnosis of schizoaffective disorder?
YesNo

Do you currently, or have you ever had a diagnosis of psychosis or psychopathy?
YesNo

Do you have currently, or have you ever had any mental health disorder diagnosis?
YesNo

Have you currently, or have you ever attempted suicide?
YesNo

If yes, how many times and what dates? If yes, please explain:

Do you currently take any mental health medications?
YesNo

If yes, please explain:

Physical Health:

Are you a diabetic?
YesNo

If so, do you take insulin by injection?
YesNo

Have you ever, or do you currently suffer from seizures?
YesNo

Are you able to navigate the community independently (bus, bike, walk, drive, etc..)
YesNo

Can you get up and down stairs?
YesNo

Do you need any special accommodations for any health reasons?
YesNo

If yes, please explain:

Do you currently take any medications for your physical health?
YesNo

If yes, please list them: