Intake Assessment

Initial Intake Assessment
No there hasn’t been any changes within the last 90 days please check box
Yes there has been changes within the last 90 days please check the box

Demographic Information: SECTION 1

Name *

First

Last

Birthdate *

Email *

Age *

Assessment Date *

Address *

Address Line 1

City

State

Zip Code

Phone *

Social Security #: *

Referral Email: *

Race/Ethnicity: *

Referral Contact: *

Referral Phone *

Marital Status: *

Referral Agency: *

Location of Service *

Reason for Referral/ Presenting Problems: SECTION 2

Client’s reason:

Family’s reason:

Referral’s source:

Current/Past Housing: SECTION 3

Client Currently Lives with: *

How many Children and Ages/Gender: *

History of Homelessness: *

Yes
No

(if yes, please explain)

History of Eviction: *

Yes
No

History of Housing less than 12 months in one place:

Yes
No

(if yes, please explain)

Currently have Transportation? *

Yes
No

Describe Current Living Situation: *

Employment: SECTION 4

Currently Employed: *

Yes
No

Previous Employment:

If yes, current employer:

Employment Interests/Skills/Concerns:

Job Title

Education: SECTION 5

Name of School: *

Special Education Services: *

Yes
No

Recent Academic Grades/GPA: *

What is the client’s classification

Legal History: SECTION 6

Needs: SECTION 7

Strengths SECTION 8

Client’s Strengths:

Recommendations:

Print Client Name *

First

Last

Signature Date

Printed Name of Case Manager *

First

Last

Signature Date