LOCAL INTAKE ASSESSMENT - Section 15 - Background Information

Local Name

First Name

Last Name

Incidents Listed on Criminal Record and Date

Current Living Arrangements

Are you Satisfied with your current living situation?

History of aggressive behavior

History of property destruction

History of antisocial behavior

this includes stealing, habitual lying, shoplifting, touching others inappropriately or uninvited, etc.

History of substance abuse

this includes drinking, smoking, or other substance abuse

Any recent major life events or changes

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