HAHOKO SCREENING TOOL

Date Date

Client Information

Client last name Client first name 

Birthdate Client birthdate 

Marital Status Client marital status

Current living arrangment Dropdown

Reffered By Dropdown 

Agency Dropdown

Point of Contact

Text field Text field Text field Text field 

Medical Information

Client diagnosis  Client substances of choice

 Medication Client must be able to take medication independently. 

Does client have medical?  Checkboxes  Dropdown

Current TB?  Checkboxes

Current Physical? Checkboxes

PCP? Checkboxes 

Client allergies  

Client health problems 

HAHOKO offers a wide variety of services, including vocational training which is mandatory. Clients recieve training in different feilds such as Handyman Services, Landscaping, Commercial Cleaning, Foodservice, and more.

Does the applicant have any physical conditions that will hinder from participating in vocational training?  Checkboxes 

Please explain bellow. 

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Criminal History

Are you a convicted felon? Checkboxes

Please list offences
Paragraph

Text field  Text field  

Are you a sex offender? Checkboxes

Client Benefits 

Check all that apply  Checkboxes

Source of Income? Checkboxes  

Toatal Income?  Text field

 

 EmploymentHistory

 

 

 

CAGE-AID 

1. Have you ever felt you should cut down on your drinking or drug use? Dropdown

2. Have people annoyed you by criticizing your drinking or drug use? Dropdown

3. Have you ever felt bad or guilty about your drinking or drug use? Dropdown

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (eye opener)? Dropdown