Intake Assessment Please enable JavaScript in your browser to complete this form.Intake AssessmentInitial Intake AssessmentNo there hasn’t been any changes within the last 90 days please check boxYes there has been changes within the last 90 days please check the boxDemographic Information: SECTION 1Name *FirstLastLayoutBirthdate *Email *Age *Assessment Date *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutPhone *Social Security #: *Referral Email: *Race/Ethnicity: *Referral Contact: *Referral Phone *Marital Status: *Referral Agency: *Location of Service *Reason for Referral/ Presenting Problems: SECTION 2LayoutClient’s reason:Family’s reason:Referral’s source:Current/Past Housing: SECTION 3LayoutClient Currently Lives with: *Choose OneSelf OnlySpouse OnlyChildren OnlySpouse and ChildrenSignificant OtherSignificant Other and ChildrenParent (s)OtherHow many Children and Ages/Gender: *History of Homelessness: *YesNo(if yes, please explain)History of Eviction: *YesNoHistory of Housing less than 12 months in one place: YesNo(if yes, please explain)LayoutCurrently have Transportation? *YesNoDescribe Current Living Situation: *Employment: SECTION 4LayoutCurrently Employed: *YesNoPrevious Employment:If yes, current employer:Employment Interests/Skills/Concerns:Job TitleEducation: SECTION 5LayoutName of School: *Special Education Services: *YesNoGrade Level or Highest Level of Education: *If yes:IEP504 PlanSpeech Therapydownload"N/A" if this doesn't apply Recent Academic Grades/GPA: *What is the client’s classification Legal History: SECTION 6LayoutCurrent Legal Status: *No Legal ProblemsPending ChargesProbationHouse ArrestIncarcerationDCS CourtOtherPlease explain if checked other than no history of legal problems:History *No History of Legal ProblemsHistory of being on ProbationHistory of being incarceratedLegal Problems related to Drugs and/or Alcohol usePlease explain if checked other than no legal problems:Needs: SECTION 7LayoutFood Pantries?YesNoCDLsYesNoAssociate in Early Childhood EducationYesNoFelony ExpungedYesNoCDAYesNoCoatsYesNoGEDYesNoChild CareYesNoWrap-around servicesYesNoDiapersYesNoCDL EndorsementYesNoBachelors in Early Childhood EducationYesNoStrengths SECTION 8LayoutClient’s Strengths:Recommendations: LayoutPrint Client Name *FirstLastSignature DateLayoutPrinted Name of Case Manager *FirstLastSignature DateSubmit