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

Layout

Birthdate *

Email *

Age *

Assessment Date *

Address *

Address Line 1

City

State

Zip Code

Layout

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

Layout

Client’s reason:

Family’s reason:

Referral’s source:

Current/Past Housing: SECTION 3

Layout

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)

Layout

Currently have Transportation? *

Yes
No

Describe Current Living Situation: *

Employment: SECTION 4

Layout

Currently Employed: *

Yes
No

Previous Employment:

If yes, current employer:

Employment Interests/Skills/Concerns:

Job Title

Education: SECTION 5

Layout

Name of School: *

Special Education Services: *

Yes
No

Recent Academic Grades/GPA: *

What is the client’s classification

Legal History: SECTION 6

Layout

Needs: SECTION 7

Layout

Strengths SECTION 8

Layout

Client’s Strengths:

Recommendations:

Layout

Print Client Name *

First

Last

Signature Date

Layout

Printed Name of Case Manager *

First

Last

Signature Date