Kirkland Ministries, Inc.

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The Kirkland Ministries, Inc. Services Questionnaire (SQ) is designed to collect information from prospective clients/individuals regarding the type of service(s) he or she needs. The information that is provided is confidential and only shared with the providing clinician(s).

Please take the time to honestly answer all the questions. Your accuracy and detail will better assist the clinician with finding services to meet your needs.

Preferred Contact Method *

Please provide information for the preferred contact method. *

Instructions
Only complete the section(s) that is/are applicable to the service(s) requested.

Community Habilitation Services

Which component of Home Community Based Services (HCS) best meets your needs? *

Other: What are additional services of interest in the Home Community Based Services Program? (If applicable) adaptive aids, home modifications, social worker, nursing, etc. *

Texas Home Living

Targeted Case Management and Rehabilitative Services

Instructions

Only complete the section(s) that is/are applicable to the service(s) requested. *

Select this option only if you desire information on all services and then submit the questionnaire without completing the rest of the fields below.

Biopsychosocial Needs Assessment Case Planning Case Monitoring Crisis Intervention Psychoeducation i.e. explaining mental health conditions in group or individual setting Individual and/or Group Counseling Day Habilitation Services/Community Habilitation Services

Other: What additional service(s) is of interest? i.e. speech therapy, physical therapy, occupational therapy etc. *