Client Details Client/Parent/Guardian Child / Dependent Housing Information Medical Information Pregnancy Income Source Experience of Violence Suicide Risk Self-Harm Substance-abuse Have you attended Miscellaneous Case sheet Consent Form

@foreach($clientGuardian as $guardian)

First Name

Last Name

Address

Identfication Number(ID)

Gender

Phone Number

First Nation Band

Date of Birth

Leave a message on the voicemail?

Email You?

Identity

Emergency Contact

Name

Relationship

Phone Number

Safe to leave message with?

Involved with

@endforeach

@foreach($clientDependent as $dependent)

First Name

Last Name

Date of birth

Address

School

Grade

Identification No.

First Nation Band

Identity

Lives With

Notes

@isset($dependent) {{$dependent->dependent_notes}} @endisset

@endforeach

Housing

Name of Shelter/Facility

Worker

How long Homeless/Under-Housed?

Phone Number

Family Doctor/clinic

Phone Number

Address

Physical health concerns

Physical disablities/mobility difficulties (person/type)

Do you need any accessibility support?

Type

Psychologist/Therapist/ Psychiatrist:

Address

Phone Number

Mental Health Concerns

Learning or Developmental Delays?

Name

Name 2

Age 1

Age 2

Medications (for physical and mental health)

@foreach($patientMedication as $pm) @endforeach

Patient Name	Medication & Dose	Purpose

Midwife/Obstetrician

Address

Phone Number

How Many Weeeks?

Any Concerns?

Risk For

Income Source

Other Income Source

Domestic/Partner/Intimate Violence

Current Safety Risk?

If you answer yes, please answer the following questions?

Police Involvement?

Physical Injuries Occured?

Charges Laid?

Where is the person now?

Do you still have concerns for safety of you and/or children from this person?

Do you have a current safety plan for you and/or your children?

Other forms of Violence

Current Plan?

Access to method

Previous attempts?

Alcohol or drug use involved with attempts in the past?

How many previous attempts?

Dates of most recent attempt

Access to Supports?

Name 1

Name 2

Phoen 1

Phone 2

Current Use

How frequently do you self-harm?

Have you ever been hospitalized for injuries as a result of self-harm?

When

Where

What purpose does the self harm have for you?

What form of self-harm do you usually use?

Current substance use/abuse

Frequency of use

Gambling/gaming/process addictions (specify)

Frequency

When

Where

Prescription drug abuse/dependency?

Drug

Length of use

substances/Addiction treatment

@if(isset($clientSupport) && $clientSupport->substances_treatment == "Yes")

Where

When

@endif

Mental health supports

@if(isset($clientSupport) && $clientSupport->mental_health_support == "Yes")

Where

When

@endif

Domestic Violence(e.g. shelter)

@if(isset($clientSupport) && $clientSupport->domestic_violence_where == "Yes")

Where

When

@endif

Sexual assault/abuse

@if(isset($clientSupport) && $clientSupport->sexual_abuse_when == "Yes")

Where

When

@endif

Healing Lodge

@if(isset($clientSupport) && $clientSupport->healing_lodge_where == "Yes")

Where

When

@endif

Others

@if(isset($clientSupport) && $clientSupport->support_others_where == "Yes")

Where

When

@endif

Reasons for seeking support at Niijkiwendidaa

@isset($clientMiscellieneous) {{$clientMiscellieneous->miscellieneous_reason}} @endisset

What aspects of your culture are you involved in? What might we do here to support you in that area?

@isset($clientMiscellieneous) {{$clientMiscellieneous->aspects_involved}} @endisset

What current strengths, supports and resources do you have? (Mental, emotional, physical, spiritual)

@isset($clientMiscellieneous) {{$clientMiscellieneous->strength_support}} @endisset

Who are the people you count on for support? (Can include Elders, family, teachers, etc.)

@isset($clientMiscellieneous) {{$clientMiscellieneous->people_count}} @endisset

What are your goals that you want help from Niijkiwendidaa with?

@isset($clientMiscellieneous) {{$clientMiscellieneous->goals_you_want}} @endisset

Do you need additional support with

@isset($clientMiscellieneous) {{$clientMiscellieneous->additional_support}} @endisset

How often do you want to meet

@isset($clientMiscellieneous) {{$clientMiscellieneous->often_you_meet}} @endisset

@foreach($ClientCasesheet as $casesheet)

Client Name

Staff

Program

Date of Contact

Length of Session

Service

Contact Type

Location

Contact

Status

Actions from sessions

Summary of Appointment

@endforeach

Internal Consent Form

@foreach($internalConsents as $internal)

@endforeach

External Consent Form

@foreach($externalConsents as $internal)

@endforeach

Emergency Contact

Medications (for physical and mental health)

If you answer yes, please answer the following questions?

Internal Consent Form

{{ $internal->file_name }}

External Consent Form

{{ $internal->file_name }}