Home
About
Services
Trauma
Contact
Home
About
Services
Trauma
Contact
Home
About
Services
Trauma
Contact
Good Samaritan Needs Assessments Feedback
Whether physical, emotional, or spiritual, your insight can help guide meaningful outreach and practical support to those who need it most.
After discussion of the in Military Veteran's need analysis this needs to be compiled by the Good Samaritan.
Good Samaritan Needs Assessments Feedback
Personal Info
First Name
Last Name
Email
Phone/Mobile
Previous
Next
1. Veteran Organization you belong to?
CMVO
SADFA
61 MVO
PVO
Unsure
Other:
Previous
Next
2. Name of Military Veteran
and Contact number
3. Veteran Organization name the member belongs to and their member number:
4. Date Military Veteran was visited:
5. Primary Reason for visit:
Emotional Support
Death of a Loved One
Homicide
Suicide
Fatal Accident
Car Hijack
Home Invasion
Other:
6. Safety Intervention: Are there any immediate threats to life that need urgent attention?
Yes
No
Unsure
Other:
7. Safety Intervention: If the answer above is yes, please indicate threats:
Threatened by a Family member (includes in-laws)
Threatened due to Domestic violence or abuse
Threatened by criminals
Threatened by neighbors or community
Feels unsafe in home
Feels unsafe in area
Other:
8. Safety Intervention: Assessment and support recommendations:
9. Belonging Intervention: Do they have relevant support structures in place?
Yes
No
Unsure
Other:
10. Belonging Intervention: If the answer above is yes please indicate support structure(s)
Family support (includes in-laws)
Church support
SADFA Unit support
Other Veteran Organization support
Support from friends
Other:
11. Belonging Intervention: Assessment and support recommendations:
12. Livelihood Intervention: In which of the following areas do they need support?
They don't have a place to stay
They don't have food to eat
They don't have running water
They don't have electricity
They don't have transport
No additional support is required
Other:
13. Livelihood Intervention: Assessment and support recommendations:
14. Emotional Intervention: How would you rate the emotional state of the person?
Critical / High Risk: Emotional state poses serious risk to the person or others.
Crisis / Acute Emotional Distress: Intense fear, panic or emotional breakdown.
Distressed / Overwhelmed: Emotions become stronger and harder to manage.
Concerned / Uneasy: The person shows mild stress or worry.
Calm / Stable: The person feels balanced, safe and emotionally in control.
Other:
15. Emotional Intervention: Assessment and support recommendations:
16. Spiritual Intervention: Assessment and support recommendations:
17. Overall Intervention: Which next steps do you recommend?
An emotional assessment is urgently required
They need to speak to a counsellor
They need to speak with a Pastor/Chaplain
They need an emotional support structure
They need to attend the "Storms of Life" course
They need to be assigned a Veteran "Champion" to journey with them
They need financial support
They will need ongoing medical support
Other:
18. Overall Intervention: Assessment and support recommendations:
19. Has a follow-up visit been scheduled?
Yes
Pending
Not required
Other:
20. Additional comments?
Previous
Submit Answers
Copyright © Emmet Counselling and Coaching
Home
About
Services
Trauma
Contact
menu-circle
cross-circle
