LifeNet Questionnaire

FIRST NAME ONLY of prospective LifeNet adult*

Your first name*

Your email address*

1. What medical, neurological, and/or intellectual diagnosis(es) does the prospective LifeNet adult have?

2a. Does the prospective LifeNet adult have any CURRENT experience with (check all that apply):

Trauma? (Trauma is an emotional response to a distressing event such as bullying, sexual abuse, loss of a loved one, a natural disaster, being exposed to or experiencing domestic violence or abuse, among other examples.)
Mental illness, including depression or anxiety?
Delusions or hallucinations?
Violent behavior?
Difficulty controlling behavior?
Self-injurious behavior?
Thoughts about suicide or ending their life?
Psychiatric hospitalizations?
Feeling overwhelmed or out of control?
Substance use? (e.g. alcohol, marijuana, and/or other drugs)
Substance abuse?
Engagement (or temptation to engage) in illegal activities?
Arrest and/or police involvement?
Involvement in a lawsuit?
Mistakes with or non-adherence to medications?
Inability to perform basic activities of daily living (ADLs) such as eating, bathing, dressing, and toileting?
Excessive clutter and/or hoarding?
Being asked to leave a program, school, or place of employment?
Loss or potential loss of housing?
An unstable living environment (e.g. homeless or risking homelessness)?

2b. Does the prospective LifeNet adult have any PAST experience with (check all that apply):

3. Please tell us more about anything checked above (e.g. further explanation, context, details, how adult has responded to treatment, etc.):

4. Which medical/clinical providers does the adult have in place (types or roles only – e.g. 'therapist,' 'psychiatrist,' etc.)

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