Criminal History:
Have you been charged with or convicted of murder? Yes No
Have you been charged with or convicted of attempted murder? Yes No
Have you been charged with or convicted of assault with a deadly weapon or aggravated assault/battery? Yes No
Do you have 2 or more domestic violence charges or convictions? Yes No
Have you been charged with or convicted of lewd and lascivious acts? Yes No
Do you have to register as a sex offender? Yes No
Do you have any charges or convictions against children or elderly individuals? Yes No
Mental Health:
Do you currently, or have you ever had a diagnosis of schizophrenia/paranoid schizophrenia? Yes No
Do you currently, or have you ever had a diagnosis of schizoaffective disorder? Yes No
Do you currently, or have you ever had a diagnosis of psychosis or psychopathy? Yes No
Do you have currently, or have you ever had any mental health disorder diagnosis? Yes No
Have you currently, or have you ever attempted suicide? Yes No
If yes, how many times and what dates?
If yes, please explain:
Do you currently take any mental health medications? Yes No
If yes, please explain:
Physical Health:
Are you a diabetic? Yes No
If so, do you take insulin by injection? Yes No
Have you ever, or do you currently suffer from seizures? Yes No
Are you able to navigate the community independently (bus, bike, walk, drive, etc..) Yes No
Can you get up and down stairs? Yes No
Do you need any special accommodations for any health reasons? Yes No
If yes, please explain:
Do you currently take any medications for your physical health? Yes No
If yes, please list them:
I agree that my submitted data is being collected and stored.
