NEW The Lotus Foundation
Comprehensive Referral, Intake & Progress Record
REVIEW DRAFT
Healing Happens Here. Hope Begins Today. Case number: LF----
Assigned upon receipt. Example: LF-0001-09-13-2026. Referral date: __________
Date received: __________ Intake completion date: __________
Program entry date, if applicable: __________ Welcome Let’s start with what you need. You do not have to answer everything today. You can skip a question, take a break, or ask someone to help. An estimate is okay when you do not remember a date or amount. You can begin even if you do not have a home address, phone, email, or paperwork. We ask these questions to understand what support may help you. Some information also helps The Lotus Foundation understand how its programs are working and prepare funding reports. Staff can explain why a question is being asked. For any question, you can choose: ☐ I’m not sure
☐ This does not apply to me
☐ I’d rather skip this
☐ I’d rather talk with someone Applying does not guarantee a place in a program. Staff will explain available services and any information needed to qualify. Need help right now?
This form is not checked for emergencies. Call 911 for immediate danger or a medical emergency. Call or text 988 for mental health, suicide, or alcohol/drug crisis support. PART 1 — LET’S GET STARTED 1. How would you like to complete this? ☐ On my own
☐ With someone from The Lotus Foundation
☐ With someone I trust
☐ I would like someone to read the questions to me
☐ I’m not sure yet Who is answering? ☐ I am asking for help for myself
☐ I am helping someone answer
☐ I am referring someone for help
☐ I am a staff member If someone is helping, what is their name and relationship to you? Would anything make this easier? ☐ Larger words on the page
☐ A different language
☐ Someone to explain the questions
☐ More time or breaks
☐ A private place to talk
☐ Something else: __________ 2. What would you like help with first? Pick as many as you want. ☐ A place to stay
☐ Food, clothes, or everyday needs
☐ My health or how I’m feeling
☐ Alcohol or drug use
☐ Money or benefits
☐ School or learning something new
☐ Finding or keeping a job
☐ Using a phone or computer
☐ Getting to appointments or other places
☐ Caring for my family
☐ Everyday tasks
☐ Meeting people or finding support
☐ Something else: __________
☐ I’m not sure—please help me figure it out Which need matters most today? Is there a date we should know about? For example, you may need to leave a place, leave a hospital, go to court, or start a program. ☐ Yes: __________
☐ No
☐ I’m not sure 3. What name should we use? Name you would like us to use: __________ Name on your records, if different:
First: __________
Middle name or initial: __________
Last: __________ When were you born? __________
☐ I’m not sure of the exact date What name or words should we use when talking about you?
For example, your pronouns. You can skip this. 4. How can we reach you safely? ☐ Call me
☐ Text me
☐ Email me
☐ Contact someone I trust
☐ I do not have a steady way to be reached
☐ I’d rather make a plan with staff Phone number, if you have one: __________
Another number, if helpful: __________
Email, if you have one: __________ Is it okay to leave a voicemail? ☐ Yes ☐ No ☐ I’m not sure Is it okay to say the message is from The Lotus Foundation? ☐ Yes ☐ No ☐ Ask me first What days or times work best? Is there anything we should do—or avoid—to contact you safely? If you want us to contact someone you trust: Their name: __________
How they know you: __________
Their phone or email: __________ May we contact them to help arrange a conversation with you? ☐ Yes ☐ No If you do not have a steady way to be reached:
Complete with staff. Where/how we will reconnect: __________
Date or time, if agreed: __________
Staff member responsible: __________ 5. Where are you staying or receiving mail? Where are you staying right now?
An address, area, or general location is okay. You can also discuss it privately. ☐ I do not have a steady place to stay
☐ I’d rather talk about this City or county: __________
State: __________
ZIP code, if known: __________ Can you safely get mail there? ☐ Yes ☐ No ☐ I’m not sure Another mailing address, if you use one: ZIP code of your last steady address, if known: __________ 6. What language or support works best for you? Language you use most: __________
Other languages you use: __________
Language you would like us to use: __________ Would you like an interpreter? ☐ Yes ☐ No ☐ I’m not sure Do you need help with reading, writing, hearing, seeing, speaking, or using this form? ☐ Yes ☐ No ☐ I’d rather talk about it What would help? 7. A little more about you You may skip these questions. Staff can explain whether any are needed for a particular program. How do you describe your gender? How do you describe your race?
Choose all that fit. ☐ American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Middle Eastern or North African
☐ Native Hawaiian or Pacific Islander
☐ White
☐ I describe myself another way: __________
☐ I’m not sure
☐ I’d rather skip this Do you identify as Hispanic or Latino? ☐ Yes ☐ No
☐ I describe myself another way: __________
☐ I’m not sure ☐ I’d rather skip this Where were you born?
City, state, or country—optional. Which best describes your relationship status? ☐ Single ☐ Married ☐ Separated ☐ Divorced
☐ Widowed ☐ In a relationship/domestic partnership
☐ Another answer: __________
☐ I’d rather skip this Have you served in the military? ☐ Yes, in the past
☐ Yes, I am serving now
☐ No
☐ I’m not sure Do you receive military or veteran support or benefits? 8. How did you find The Lotus Foundation? ☐ Friend or family member
☐ Doctor, counselor, or other healthcare worker
☐ Hospital or treatment program
☐ Community group
☐ School or job-training program
☐ Court, probation, parole, or reentry program
☐ Website or social media
☐ Another way: __________ Have you received help from The Lotus Foundation before? ☐ Yes ☐ No ☐ I’m not sure If yes, what help and about when? Previous case number, if known: __________ If someone referred you Their name: __________
Organization and role: __________
Phone or email: __________ Do you know about this referral? ☐ Yes ☐ No ☐ Staff need to check Have you agreed to be contacted directly? ☐ Yes ☐ No ☐ Staff need to check Who should staff contact first? __________ 9. Would you like to keep going? ☐ Yes
☐ I would rather finish with someone
☐ I need a break
☐ I would like to stop for today Staff can record where to restart. You do not need to repeat answers already given. PART 2 — YOUR HOME & PEOPLE IN YOUR LIFE 10. Who lives with you? How many people usually live or stay with you, including you? _____ How many are adults? _____
How many are children under 18? _____
☐ I’m not sure For each person, tell us: Name or initials: __________
How they are related to you: __________
Age, or date of birth if needed for a program: __________
Gender, optional: __________
Do they need help with anything? __________ Repeat for each person. Staff can help write the answers. Do you help support children or other family members who live somewhere else? ☐ Yes ☐ No ☐ I’m not sure For each person: Name or initials: __________
How they are related to you: __________
Age, if known: __________
What care or support do you provide? __________
What help is needed? __________ 11. Who supports you? Who can you count on when you need help? What do they help with? Are there family relationships that make things harder for you? ☐ Yes ☐ No ☐ I’d rather talk privately Tell us only what you want us to know: Are there people we should not contact? Does anyone in your family need support of their own? 12. Do you care for children or other dependents? ☐ Yes ☐ No
☐ I help care for someone, but they do not live with me If no, skip to Section 13. Who do you care for, and how old are they? Do they live with you all the time, some of the time, or somewhere else? For children under age 6, do they attend any of these? ☐ Childcare
☐ Preschool
☐ Head Start or Early Head Start
☐ Early intervention or another child-development program
☐ None right now
☐ I’m not sure Program name, if known: __________ For school-age children: School and grade: __________
After-school activities: __________ Is getting to or staying in school difficult? ☐ Yes ☐ No ☐ Sometimes What help would make a difference? Do any children or dependents need help with learning, development, health, or daily care? Is childcare or caregiving making it hard for you to work, learn, or attend appointments? Has a child welfare agency been involved with your family? ☐ Now ☐ In the past ☐ Both
☐ No ☐ I’m not sure ☐ I’d rather talk privately Is there anything about that situation staff should know to help you? What is going well in caring for your family? What support would help you meet their needs safely? 13. Do you feel safe in your relationships? We ask so we can offer support and contact you safely. You can skip this or talk privately. Has a partner or someone close to you hurt, threatened, controlled, or made you afraid? ☐ This is happening now
☐ This happened in the past
☐ Both
☐ No
☐ I’m not sure
☐ I’d rather talk privately About when, if you want to share? Do you need help with safety, a place to stay, or contacting support? Is there anything we should avoid doing that could put you at risk? Do you already have support or a plan that helps you stay safe? 14. Where are you staying right now? Choose the answer that fits best. ☐ A home I own
☐ A place I rent
☐ With friends or family
☐ A hotel or motel
☐ A shelter
☐ A shelter for people leaving an unsafe relationship
☐ Temporary housing through a program
☐ Recovery housing
☐ Outside, in a car, or somewhere not meant for sleeping
☐ A hospital
☐ A mental health treatment facility
☐ An alcohol or drug treatment facility
☐ Jail or prison
☐ Foster care
☐ Somewhere else: __________
☐ I’d rather talk about it About how long have you been staying there? Does the place meet your needs and feel safe enough? ☐ Yes ☐ No ☐ Sometimes ☐ I’m not sure What concerns do you have? Could you lose this place or need to leave soon? ☐ Yes ☐ No ☐ I’m not sure About when, and why? 15. Do you get help paying for housing? ☐ Yes ☐ I have applied ☐ No ☐ I’m not sure Program name, if known: __________
Amount of help, if known: __________
When did you apply or last renew? __________ Have you applied for another place or housing program? ☐ Yes ☐ No ☐ I’m not sure Program/place and application date, if known: Do you need help with an application or renewal? 16. What housing costs do you pay? Do you currently pay rent? ☐ All of it ☐ Part of it ☐ None ☐ This does not apply About how much each month? $_____
☐ I’m not sure Do you currently pay utilities, such as power or water? ☐ All of them ☐ Part of them ☐ None ☐ This does not apply About how much each month? $_____
☐ I’m not sure At your previous place, did you pay rent? ☐ All ☐ Part ☐ None ☐ This does not apply At your previous place, did you pay utilities? ☐ All ☐ Part ☐ None ☐ This does not apply Are you behind on rent or utilities, or have you received a shutoff notice? ☐ Yes ☐ No ☐ I’m not sure What help do you need? 17. Have you been without a steady place to stay? Are you without a steady place now? ☐ Yes ☐ No ☐ I’m not sure About how long has this been going on this time? ☐ Less than a month
☐ One to five months
☐ Six to eleven months
☐ One year to less than two years
☐ Two years to less than three years
☐ Three years or more
☐ I’m not sure
☐ This does not apply About when did it start, if you remember? In the past five years, about how many separate times have you been without a steady place?
_____ ☐ I’m not sure About how many times in your life?
_____ ☐ I’m not sure Your best estimate is okay. 18. Where have you stayed recently? In the past 30 days, where have you slept?
You may choose more than one answer. ☐ My own or rented place
☐ With friends or family
☐ Hotel or motel
☐ Shelter
☐ Temporary or recovery housing
☐ Outside or in a car
☐ Hospital or treatment facility
☐ Jail or prison
☐ Foster care
☐ Somewhere else: __________ About when or for how long? During the past four years, have you stayed in shelters? ☐ Yes ☐ No ☐ I’m not sure For each stay you remember: Shelter name, if known: __________
About when: __________
About how many nights or months: __________ 19. What has made it hard to keep housing? Have you ever been evicted? ☐ Yes ☐ No ☐ I’m not sure About when, and what happened? Have any of these caused you to leave a place? ☐ Could not afford rent
☐ Eviction for another reason
☐ Problems with friends or family
☐ Too many people in the space
☐ Violence or an unsafe situation
☐ Going to jail or prison
☐ Going to a hospital or treatment program
☐ Building was unsafe or closed
☐ Fire or disaster
☐ Something else: __________ What makes finding or keeping housing difficult now? What kind of place would work for you? Housing history—complete with help if needed Tell us about places you stayed during the past five years. For each place: Place or type of housing: __________
About when you stayed there: __________
Was it in your name or someone else’s? __________
Why did you leave? __________ Approximate dates are okay. Staff can add continuation entries. PART 3 — HEALTH & SUPPORT 20. Do you have health coverage? ☐ Medicaid
☐ Medicare
☐ Insurance through work or another plan
☐ Another kind: __________
☐ I have applied
☐ I do not have coverage
☐ I’m not sure Plan name, if known: __________ Do you need help getting or using coverage? 21. Does a health condition or disability affect everyday life? ☐ Yes ☐ No ☐ I’m not sure ☐ I’d rather talk privately What would you like us to know? About how long has it affected you? What everyday things are harder because of it? Have you ever been told by a healthcare professional that you have any of these? For each, you may answer: Now / In the past / Both / No / Not sure / Skip. * A mental health condition: __________ * An alcohol use disorder: __________ * Another substance use disorder: __________ * HIV/AIDS or a related condition—optional: __________ * A developmental or intellectual disability: __________ * A physical disability: __________ * Another long-term health condition: __________ If a program needs paperwork about a condition, do you have any? ☐ Yes ☐ No ☐ I’m not sure You do not need to find paperwork before beginning this form. 22. Where do you get healthcare? Do you have a doctor, clinic, or other healthcare provider? ☐ Yes ☐ No ☐ I’m not sure For each provider, if known: Name or clinic: __________
Type of care: __________
Phone: __________
Address: __________
Last or next visit: __________ Are there health concerns you need help with now? Have you stayed in a hospital for a medical problem? ☐ Yes ☐ No ☐ I’m not sure If relevant to your support, tell us: Hospital: __________
About when: __________
Reason: __________
Follow-up help needed: __________ 23. Are there checkups or other care you need? About when was your last general checkup? __________
Last dental visit? __________
Last reproductive-health or OB/GYN visit, if applicable? __________ Do you need help with any of these? ☐ Medical care ☐ Dental care ☐ Vision ☐ Hearing
☐ Reproductive healthcare ☐ Other care: __________
☐ I’m not sure Does anyone in your household need help getting healthcare? What makes getting care difficult? ☐ Cost ☐ Transportation ☐ Scheduling
☐ Childcare/caregiving ☐ Finding a provider
☐ Understanding paperwork ☐ Something else: __________ 24. Do you take any medicines? ☐ Yes ☐ No ☐ I’m not sure ☐ I’d rather talk with someone You can use a medicine list, bring the containers, or ask staff to help. It is okay if you do not know a name or dose. Please do not guess. Please include medicines for physical health, mental health, or alcohol/drug treatment. You may also include medicines you buy without a prescription, vitamins, or supplements. Tell us about each medicine What is the medicine called? __________ How much do you take each time? For example: one tablet or 10 mg. __________ ☐ I’m not sure How often do you take it? For example: each morning, twice a day, or only when needed. __________ ☐ I’m not sure What do you take it for, if you know? __________ ☐ I’m not sure ☐ I’d rather skip this Who prescribes it or helps manage it? The person’s name or clinic is enough. __________ ☐ I’m not sure ☐ I buy it without a prescription Are you taking it now? ☐ Yes ☐ Sometimes ☐ No, I stopped ☐ I ran out or cannot get it ☐ I’m not sure Anything you would like us to know about this medicine? __________ Repeat these questions for each medicine. Staff may use the table below to record the answers instead; you do not need to fill out both. Medication list — staff may help complete | Medicine name | Dose—how much each time | Frequency—how often | Purpose, if known | Prescriber/provider, if known | Taking now or having trouble getting it? | | --- | --- | --- | --- | --- | --- | | __________ | __________ | __________ | __________ | __________ | __________ | | __________ | __________ | __________ | __________ | __________ | __________ | | __________ | __________ | __________ | __________ | __________ | __________ | | __________ | __________ | __________ | __________ | __________ | __________ | Allergies and reactions Have you ever had an allergy or a bad reaction to a medicine? ☐ Yes ☐ No ☐ I’m not sure ☐ I’d rather talk with someone Which medicine, if you know? __________ What happened when you took it? __________ Do you have other allergies we should know about? For example: food, latex, or insect stings. ☐ Yes ☐ No ☐ I’m not sure What are you allergic to, and what happens? __________ Getting and taking your medicines Would you like help with any of these? Choose as many as you want. ☐ Paying for medicine ☐ Finding a provider who can prescribe it ☐ Getting a prescription or refill ☐ Getting to the pharmacy ☐ Having medicine delivered, if available ☐ Remembering when to take it ☐ Understanding the label or instructions ☐ Opening the container or measuring a dose ☐ Finding a safe place to keep it ☐ Keeping it cold, if needed ☐ Talking with a provider about side effects ☐ Something else: __________ ☐ No help needed right now ☐ I’m not sure Are you out of a medicine you need, or close to running out? ☐ Yes ☐ No ☐ I’m not sure Which medicine? About how much is left, if you know? __________ Does anyone help you get or take your medicines now? ☐ Yes ☐ No Who helps, and what do they help with? __________ What extra help would make things easier? __________ 25. How have you been feeling? You can answer privately with staff. You do not need to describe upsetting experiences in detail. For each question, choose: Now / In the past / Both / No / Not sure / Skip. Have you had times when… * You felt very sad, hopeless, or had major changes in mood? __________ * You felt very worried, afraid, or affected by a frightening experience? __________ * You heard or saw things other people did not seem to hear or see? __________ * You had thoughts or beliefs that others did not share or found hard to understand? __________ * Your thoughts felt very confused or hard to organize? __________ * Remembering things or concentrating was difficult? __________ * You thought about suicide or hurting yourself? __________ * You tried to end your life or hurt yourself? __________ * You thought about seriously hurting someone else? __________ * You tried to seriously hurt someone else? __________ * You acted aggressively or physically hurt someone? __________ * You deliberately set a fire that could harm someone or damage property? __________ * Someone sexually hurt or assaulted you? __________ * You experienced another kind of abuse or deeply upsetting event? __________ Anything else about how you are feeling that you want us to know? Is there a safety concern you need help with now? What helps you feel safer or calmer? Do you have a safety plan or someone you contact when things are difficult? Staff should respond to urgent concerns right away through the appropriate process. These questions do not replace a clinical safety assessment. 26. Have you gotten mental health support before? ☐ I get support now
☐ I got support in the past
☐ Both
☐ No
☐ I’m not sure For each provider or program: Name: __________
Phone/address, if known: __________
Type of help: __________
About when: __________ Have you stayed in a hospital for mental health support? ☐ Yes ☐ No ☐ I’d rather talk privately Hospital and approximate dates: __________
Reason, if you wish to share: __________
Help needed after leaving: __________ What support helped you? What did not work well for you? What would you like help with now? Medicines for mental health Do you take medicine to help with your mood, sleep, thoughts, or other mental health needs? ☐ Yes ☐ No ☐ I’m not sure ☐ I’d rather talk privately If you already listed it in Section 24, you do not need to list it again. Is there another medicine we should add? Staff can help record the name, dose, how often you take it, and provider if known. | Medicine name | Dose, if known | How often | Provider, if known | | --- | --- | --- | --- | | __________ | __________ | __________ | __________ | | __________ | __________ | __________ | __________ | Is the medicine helping in the way you hoped? ☐ Yes ☐ Somewhat ☐ No ☐ I’m not sure Is there anything you want help discussing with your provider? For example: side effects, getting refills, or difficulty taking it. __________ 27. Would you like help related to alcohol or drugs? ☐ Yes ☐ Maybe ☐ No ☐ I’d rather talk privately Has alcohol or drug use caused concerns for you? ☐ Now ☐ In the past ☐ Both ☐ No ☐ I’m not sure If you are comfortable sharing, tell us about each substance: Substance: __________
About how often/how much: __________
About when you last used it: __________
How it affects everyday life: __________ Have you had an overdose, felt sick when stopping, or had another urgent concern? Has use affected housing, relationships, work, health, or legal matters? 28. What recovery support works for you? Have you received alcohol or drug treatment? ☐ Now ☐ In the past ☐ Both ☐ No ☐ I’m not sure Provider/program: __________
Phone/address, if known: __________
Type of treatment and approximate dates: __________ Was it helpful? What would you change? Do you take part in any support groups or recovery programs? ☐ Peer support ☐ 12-step/mutual-help group
☐ Counseling ☐ Another program: __________
☐ None right now Medicines used in alcohol or drug treatment Do you take medicine as part of alcohol or drug treatment? ☐ Yes ☐ No ☐ I’m not sure ☐ I’d rather talk privately If you already listed it in Section 24, you do not need to list it again. Is there another medicine we should add? | Medicine name | Dose, if known | How often | Provider/program, if known | | --- | --- | --- | --- | | __________ | __________ | __________ | __________ | | __________ | __________ | __________ | __________ | Do you need help reaching the provider, getting the medicine, or getting to appointments? __________ Would you like to talk with a healthcare provider about medicine that may support your treatment or recovery? ☐ Yes ☐ No ☐ Maybe ☐ I’d rather talk privately If cutting back or stopping is one of your goals, how has that been going? What kind of support would you prefer? What might make getting support difficult? PART 4 — EVERYDAY NEEDS, LEARNING & WORK 29. What helps you feel connected? Are there people, groups, or activities you enjoy? Do you take part in community, cultural, faith, or spiritual activities?
Share only if you want to. Do you sometimes feel alone or have trouble joining activities? ☐ Yes ☐ No ☐ Sometimes What connections or activities would you like help finding? 30. Do you get money or benefits for everyday needs? ☐ Yes ☐ No ☐ I’m not sure ☐ I’d rather talk with staff Does anyone else in your household receive money or benefits? ☐ Yes ☐ No ☐ I’m not sure Which sources apply? ☐ Work or self-employment
☐ SSI
☐ SSDI
☐ Retirement/Social Security
☐ General assistance
☐ TANF/cash assistance
☐ Child support
☐ Alimony
☐ Veteran benefits
☐ Unemployment
☐ SNAP/food benefits
☐ Something else: __________
☐ No current money or benefits Staff can explain unfamiliar benefit names. For each source: Who receives it: __________
Source: __________
About how much: __________
How often: ☐ Weekly ☐ Every two weeks ☐ Monthly ☐ Other
Status: ☐ Receiving ☐ Applied/waiting ☐ Denied ☐ Renewal needed
Application or renewal date, if known: __________ About how much cash income do you receive in a month? $_____
☐ Not sure ☐ Skip About how much cash income does your whole household receive in a month? $_____
☐ Not sure ☐ Skip Staff will record food benefits and other noncash help separately. Does anyone need help with health coverage or another benefit? 31. Are bills or basic needs causing stress? Are you behind on bills or paying back money you owe? ☐ Yes ☐ No ☐ I’m not sure What kind of bill or debt? __________
About how much, if known? __________
How is it affecting you? __________ What regular costs do you pay? ☐ Housing ☐ Utilities ☐ Child support/alimony
☐ Transportation ☐ Childcare/caregiving
☐ Other: __________ Amounts, if you know and want to share: Do you have enough food, clothes, and personal-care supplies? ☐ Yes ☐ No ☐ Sometimes What would help most? 32. Are you working now? ☐ Full-time
☐ Part-time
☐ Working for myself
☐ Not working and looking for work
☐ Not looking right now
☐ Not able to work right now
☐ Retired If working: Employer/type of work: __________
Job or tasks: __________
About when you started: __________
Hours each week: __________
Pay rate, if you wish to share: __________
Benefits, if any: __________ What work have you done before? For each job or type of work: Work/employer: __________
About when: __________
Skills or tasks: __________
Reason for leaving, if relevant: __________ 33. Would you like help finding or keeping a job? ☐ Yes ☐ No ☐ Maybe later ☐ I’m not sure What kind of work interests you? What days or hours could you work? Would any of these help? ☐ Choosing a job or career path
☐ Job training or a certificate
☐ Writing a résumé
☐ Filling out applications
☐ Practicing interviews
☐ Finding job openings
☐ Support after starting a job
☐ Changes or accommodations at work
☐ Work clothes or equipment
☐ Something else: __________ Are you in a job-training or employment program now? ☐ Yes ☐ No ☐ I’m not sure Program name: __________ Would you like to join one? ☐ Yes ☐ No ☐ Maybe What could make working difficult? ☐ Transportation ☐ Childcare/caregiving ☐ Health
☐ Housing ☐ Needed documents ☐ Legal history
☐ Something else: __________ 34. What learning would you like to do? What is the last grade or school program you finished? Do you have a diploma, degree, license, or certificate? Are you in school or training now? ☐ Yes ☐ No School/program: __________
☐ Full-time ☐ Part-time ☐ Another schedule
Expected completion, if known: __________ How is it going? Would you like to start or return to school or training? ☐ Now ☐ Later ☐ No ☐ I’m not sure What would you like to learn or finish? Would you like help with reading, writing, math, or learning in another language? ☐ Yes ☐ No ☐ I’d rather talk privately How do you learn best? ☐ Someone showing me
☐ Practicing with help
☐ Listening
☐ Reading
☐ Videos
☐ Another way: __________ What could make attending or finishing difficult? Have you tried other training programs? What happened? 35. Do you have the technology you need? Do you have a phone, tablet, or computer you can use? ☐ My own ☐ Shared ☐ Borrowed ☐ None What kind? __________ Does it work well enough for what you need? ☐ Yes ☐ No ☐ Sometimes Can you get online when you need to? ☐ Usually ☐ Sometimes ☐ No What makes it hard? ☐ Cost ☐ Broken/missing equipment ☐ Weak/no internet
☐ Not sure how to use it ☐ Accessibility needs
☐ Something else: __________ 36. What would you like help doing with technology? For each, choose: I can do this / Some help / A lot of help / Have not tried / Not interested right now. * Sending email or messages: __________ * Filling out forms online: __________ * Taking an online class: __________ * Writing documents or using spreadsheets: __________ * Finding jobs or sending a résumé: __________ * Having a healthcare visit online: __________ * Staying safe and protecting information online: __________ * Using AI tools, such as ChatGPT, for learning or work: __________ * Something else: __________ What would you most like to learn? 37. Are legal matters affecting your needs? You may answer privately with staff. Do you have a legal matter or court date coming up? ☐ Yes ☐ No ☐ I’d rather skip this What should staff know to help you? Important dates: __________ Do you have an attorney or legal advocate? ☐ Yes ☐ No Name/organization: __________
Phone/address: __________ Are you on probation? ☐ Yes ☐ No
Are you on parole? ☐ Yes ☐ No Officer/agency, if relevant: __________
Contact information: __________
Requirements that affect services: __________ Have past arrests, convictions, or time in jail/prison created needs you want help with? Release date, if relevant: __________
Help needed after release: __________ 38. Does someone have legal authority to help make decisions for you? ☐ Yes ☐ No ☐ I’m not sure For example, a guardian, conservator, or someone appointed to manage benefits. Their name: __________
Phone/address: __________ What do they help decide or manage? ☐ Personal decisions
☐ Money or benefits
☐ Both
☐ Something else: __________ Are there limits to what they can do? Is paperwork available? ☐ Yes ☐ No ☐ I’m not sure Staff can help identify the person’s role and any needed documents. 39. What everyday things would you like help with? For each, choose: I manage this / Some help / A lot of help / Does not apply. * Paying rent or utilities: __________ * Understanding and following housing rules: __________ * Cleaning or doing laundry: __________ * Managing money: __________ * Driving or using transportation: __________ * Getting things repaired where I live: __________ * Getting mental health support: __________ * Getting medical care: __________ * Applying for or keeping benefits: __________ * Making meals: __________ * Shopping for food or supplies: __________ * Understanding and following medicine instructions: __________ * Remembering when to take medicines: __________ * Getting prescriptions and refills: __________ * Getting medicines from the pharmacy: __________ * Keeping medicines safely stored: __________ * Connecting or communicating with people: __________ * Bathing or other personal care: __________ * Something else: __________ Which things do you feel good about doing? Where would help make the biggest difference? Staff: Use the medication list in Section 24. Add new information from Sections 26 and 28 to that same list, and confirm updates with the participant. Keep “unknown” separate from “none.” 40. What is going well, and what would you like to change? What are you good at or proud of? What interests you or brings you comfort? What helps you keep going when things are difficult? What are up to three things you want to work toward? 1. 


 2. 


 3. 


 How would you know things were getting better? What would make it easier to work with The Lotus Foundation? Is there anything else you want us to understand? 41. Who should we contact in an emergency? Name: __________
How they know you: __________
Phone: __________
Another phone, if available: __________
Address, if useful: __________ ☐ I do not have an emergency contact right now Anything we should know before contacting them? Another emergency contact, optional: __________
Relationship/phone: __________ 42. Review & Permission to Contact ☐ My answers are correct as far as I know. Some answers may be estimates. ☐ The Lotus Foundation may contact me about this request using the safe contact choices I provided. If answering for someone else: ☐ I have permission or authority to share this information. How you know the person or your authority to help: Signing here does not give permission for treatment, sharing health records, research, or using your story or photo. Staff will explain those separately if needed. Participant or authorized representative: __________
Signature: __________ Date: __________ Person helping or making the referral, if different: __________
Date: __________ Staff/witness: __________
Signature: __________ Date: __________ Optional invitations May The Lotus Foundation contact you to ask about your experience with its programs? ☐ Yes ☐ No ☐ Ask me later May The Lotus Foundation contact you about possible research opportunities? ☐ Yes ☐ No ☐ Ask me later Saying yes only allows an invitation. It does not sign you up for research or allow a partner to see your private records. Saying no does not affect your access to services. STAFF SECTION — INTAKE & SERVICE PLANNING Participants do not need to complete this section. 43. Record the Intake Status Case number: __________
Participant record ID: __________
Staff member: __________
Date information gathered: __________ Record type: ☐ Referral ☐ Intake ☐ Continuation ☐ Update ☐ Reassessment How received: ☐ Website ☐ Paper/PDF ☐ Phone ☐ Partner ☐ Other Current status: ☐ Received
☐ Contact needed
☐ Intake started
☐ Checking program requirements
☐ Enrolled
☐ Waiting for an opening
☐ Referred elsewhere
☐ Participant declined
☐ Unable to reach
☐ Closed Where to restart if unfinished: __________
Preferred follow-up method: __________
Next action, staff member, and date: __________ 44. Check Program Fit & Information Sources Program considered: __________
Requirements reviewed: __________
Decision and reason: __________
Alternative support offered, if needed: __________ Assigned staff/program/partner: __________
Funding source or grant code, if applicable: __________
First contact date: __________
Service start date: __________ Who provided the information? ☐ Participant ☐ Referrer ☐ Authorized representative
☐ Records reviewed ☐ Other: __________ For important answers, identify whether they are: ☐ Self-reported ☐ Estimated ☐ Verified
☐ Unknown ☐ Skipped ☐ Not applicable Do not turn “not sure” or a skipped answer into “no.” Keep the participant’s meaning when entering reporting categories. 45. Track Needed Documents Request documents for an identified purpose. Explain the reason and help the participant obtain them. For each document: Document: __________
Program/purpose: __________
Date requested: __________
Date received/reviewed: __________
Reviewed by: __________
Help needed to obtain it: __________ Possible documents include: ☐ Housing/homelessness verification
☐ Disability verification
☐ Children’s education information
☐ Coverage/benefit information
☐ Representative authority
☐ Other: __________ Treatment consent status, if applicable: __________
Permission to obtain/share records and its limits: __________
Other program-specific permissions: __________ Supervisor review/signature, if applicable: __________
Date: __________ Restricted identifying information Do not put Social Security numbers in this general form. If an identified program requires a participant’s or family member’s identifier, collect it separately through the restricted process. Person/identifier needed: __________
Requirement and reason: __________
Collection/verification status: __________
Restricted record reference: __________ 46. Make a Plan Together Complete one entry for each agreed goal. What the participant wants: __________
Starting situation and date: __________
What progress would look like: __________
Action or service planned: __________
Who will help: __________
Target or review date: __________
How progress will be checked: __________
Support or accommodations needed: __________ Participant agrees with the plan:
☐ Yes ☐ Changes requested ☐ Review later Participant/representative: __________ Date: __________
Staff: __________ Date: __________ 47. Record Each Service or Contact Date: __________
Staff/provider: __________
Program/service: __________ How provided: ☐ In person ☐ Phone ☐ Video ☐ Group ☐ Other Time spent or service units: __________
What one unit means: __________ Attendance: ☐ Attended ☐ Cancelled ☐ Missed ☐ Rescheduled What support was provided? __________
Which goal did it address? __________
Participant response or progress: __________
New needs or barriers: __________
Next action, owner, and date: __________ 48. Follow Up on Partner Referrals Partner organization: __________
Service requested: __________
Referral date: __________
Contact person: __________ Permission to share information checked: __________
Information shared and limits: __________ What happened? ☐ Waiting for response
☐ Contact made
☐ Appointment scheduled
☐ Service received
☐ Waiting list
☐ Service unavailable
☐ Participant declined
☐ Unable to reach
☐ Unknown Outcome date/details: __________
Who will follow up, and when? __________ STAFF SECTION — PROGRESS & PARTICIPANT EXPERIENCE 49. Check Progress Review date: __________
Reviewer: __________ Review point: ☐ Starting assessment ☐ 30 days ☐ 90 days ☐ 180 days
☐ Exit ☐ After exit ☐ Other: __________ Use timing appropriate to the program and its funding commitments. For each relevant goal or measure, record: What is being measured: __________
Starting answer/value and date: __________
Current answer/value and date: __________
Source: ☐ Participant ☐ Partner ☐ Verified record ☐ Other
Next action: __________ Possible areas: * Housing situation and stability. * Time without steady housing during a stated period. * Monthly cash income. * Benefits obtained or kept. * Health coverage and access to providers. * Appointments attended. * Help needed with daily tasks. * School enrollment, attendance, and completion. * Credentials earned. * Device and internet access. * Digital skills. * Job placement, start date, hours, pay, and retention. * Participant-defined recovery goals. * Social support and connection. * Other participant goals. Information missing and reason: __________
New concerns, setbacks, or unexpected effects: __________
Changes agreed with the participant: __________ Use the same definitions and time periods when comparing answers. Use separate clinical or research tools where appropriate. 50. Ask About the Experience These questions may be read aloud. Participants may skip any of them. Did you feel listened to and respected? ☐ Yes ☐ Sometimes ☐ No ☐ Skip Was it easy enough to get help? ☐ Yes ☐ Sometimes ☐ No ☐ Skip Did the support focus on what mattered to you? ☐ Yes ☐ Somewhat ☐ No ☐ Skip What helped most? What could The Lotus Foundation do better? What do you still need help with? 51. Record Exit & Continuing Support Exit date: __________ Reason: ☐ Goals reached
☐ Planned services completed
☐ Moved to another provider
☐ Participant chose to stop
☐ Lost contact
☐ Program/funding eligibility changed
☐ Other: __________ Services completed: __________
Progress at exit: __________
Needs that remain: __________
Continuing supports/referrals: __________ May staff follow up? ☐ Yes ☐ No ☐ Not yet discussed
Safe contact method: __________
Follow-up date: __________
Responsible staff: __________ PROGRAM SECTION — FUNDING, EVALUATION & PARTNERSHIPS Complete at the program or project level. 52. Define What the Program Will Report Program/grant: __________
Reporting period: __________
Who the program serves: __________
Program requirements: __________
Program goals: __________ For each item reported: What will be counted or measured: __________
Exact definition: __________
Where the information comes from: __________
When it is collected: __________
Responsible staff: __________ Count these separately: * Individual participants. * Referrals. * Program enrollments. * Service visits/contacts. * Service hours or units. * Completed services. * Outcomes. * Completed follow-ups. How duplicate participant counts will be avoided: __________
Who is included in each outcome calculation: __________
Time period used: __________
Missing answers and missed follow-ups: __________
Checks for accuracy and corrections: __________ A blank answer is not “no.” A missing amount is not zero. An improvement after services does not, by itself, prove the services caused the improvement. 53. Plan Partnerships & Research Potential partner: __________
Contact person: __________ Purpose: ☐ Provide services together
☐ Improve a program
☐ Evaluate a program
☐ Conduct research
☐ Other: __________ What question or need would the partnership address? How could participants or the community benefit? What activities are proposed? What information is needed, and why? Could grouped information or information without personal identifiers meet the need? Measures, methods, and timeline: __________
Time or effort requested from participants: __________
Accessibility and support needs: __________
Separate permissions needed: __________
Organizational or ethics review needed and its outcome: __________ Who may access the information? __________
How may it be used? __________
How will it be protected? __________
How long will it be kept, and how will it be deleted? __________ Partner responsibilities: __________
Reporting/publication plans: __________
Approval status and reviewer: __________ Completing intake or agreeing to receive an invitation does not give a prospective partner access to identifiable participant records. CASE-NUMBER INSTRUCTIONS — STAFF ONLY Example: LF-0001-09-13-2026 * LF means Lotus Foundation. * 0001 is the next number in a central sequence. * 09-13-2026 is the receipt date, using Eastern Time. * The sequence does not reset and may grow beyond four digits. * Assign the case number after the referral is saved or registered. * Repeated attempts to submit the same referral should return the same receipt. * Intake updates and progress records keep the same case number. * Link separate referrals to the same participant record when appropriate. * Assign paper/PDF referrals a number when staff register them. * A case number alone does not allow access to private records.