Six Month Review Form
NorthCentral Independent Living Program. This institution is an equal opportunity provider.
Basic Information
Name
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
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December
Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
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2012
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1920
Year
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Who is your Independent Living Coordinator?
Bethany Reque
Katie Kirmse-Fuhrer
Housing
Do you currently have safe, stable housing?
Yes
No
Is anyone else living with you in your current housing situation?
Yes
No
Name & Relationship
In the last six months, have you been in an unstable housing situation or homeless?
Yes
No
How long were you in that housing situation or homless?
Do you know how to locate safe, stable and affordable housing?
Yes
No
Do you know how to budget your living expenses (i.e. rent and utility costs)?
Yes
No
How confident do you feel about your housing situation
Very Confident
Confident
Neutral
Not Confident
Very unconfident
Health & Well-Being
Do you currently have BadgerCare?
Yes
No
Do you have other insurance coverage?
Yes
No
Do you have a Primary Care Provider?
Yes
No
Name of Primary Care Provider
How many times have you went to the Emergency Room in the last six months?
0
1-3
4-6
7+
What were the primary reason(s) you went to the Emergency Room?
Do you have a mental health condition or diagnosis?
Yes
No
Are you currently receiving treatment (i.e. therapy/counseling, medication) for this?
Yes
No
Name of Treatment Provider
How confident do you feel about your health and well-being?
Very Confident
Confident
Neutral
Not Confident
Very Unconfident
Self-Care
Do you have a place to go when you are feeling unsafe?
Yes
No
Do you know how to treat minor injuries?
Yes
No
Do you know how to prevent sexually transmitted diseases?
Yes
No
Do you know how to prevent pregnancy?
Yes
No
Do you have healthy methods of dealing with stress and anxiety?
Yes
No
Do you think about how your choices impact others?
Yes
No
Do you know how to access public benefits (i.e. FoodShare, Social Security, etc.)
Yes
No
Do you show up on time/early for appointments, work, school, etc.?
Yes
No
Do you know how to keep your living space clean?
Yes
No
Do you know how to do your own laundry?
Yes
No
Do you know how to compare prices when shopping?
Yes
No
Do you have any hobbies?
Yes
No
What hobbies do you have?
How confident do you feel about your self-care skills and abilities?
Very Confident
Confident
Neutral
Not Confident
Very Unconfident
Legal
Do you have any pending charge(s)?
Yes
No
What are the pending charge(s)?
Have you had any conviction(s) in the last six months?
Yes
No
What are the conviction(s)?
Are you on probation or parole?
Yes
No
Who is your probation or parole worker?
Do you have any fine(s)?
Yes
No
How much are your fine(s)?
Education
Are you currently enrolled in school?
Yes
No
Where are you attending school?
How many semesters have you completed?
Are you interested in any education, training or apprenticeship program(s)?
Yes
No
What kind of program(s) are you interested in?
How confident do you feel about your educational level?
Very Confident
Confident
Neutral
Not Confident
Very Unconfident
Employment
Are you currently working?
Yes
No
Where are you working? For how long? How many hours per week? For what wage? What is your job title and duties?
Are you looking for a job?
Yes
No
Do you have a resume?
Yes
No
Do you have work references and their contact information?
Yes
No
Do you have personal references and their contact information?
Yes
No
Do you have your photo ID, birth certificate and other documents needed for work?
Yes
No
How confident do you feel about your employment status?
Very Confident
Confident
Neutral
Not Confident
Very Unconfident
Connections
Do you feel you have at least one supportive individual in your life?
Yes
No
Who is that individual(s)?
Do you feel this individual(s) are available during times of crisis?
Yes
No
How strong do you feel that level of support from this individual(s)?
Very Strong
Strong
Adequate
Poor
Very Poor
Do you feel there are areas in which you could use additional support?
Emotional
Physical
Financial
Other
How confident do you feel about connections you have with others?
Very Confident
Confident
Neutral
Not Confident
Very Unconfident
Help/Focus
Please let us know if you are in need of help and what you would like to focus on during the next six months.
Submit
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