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

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Date of Birth

Age

Email

Date of Assessment

Address

Address Line 1

City

State

Zip Code

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Phone

Referral Contact:

Location of Service

Race/Ethnicity:

Referral Agency:

Marital Status:

Referral Phone #:

Social Security #:

Referral Email: *

Reason for Referral/ Presenting Problems: SECTION 2

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Client’s reason:

Family’s reason:

Referral’s source:

Current/Past Housing: SECTION 3

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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)

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Currently have Transportation?

Yes
No

Describe Current Living Situation:

Employment: SECTION 4

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Currently Employed:

Yes
No

Previous Employment:

If yes, current employer:

Employment Interests/Skills/Concerns:

Job Title

Education: SECTION 5

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Name of School:

Special Education Services:

Yes
No

Recent Academic Grades/GPA:

What is the client’s classification

Legal History: SECTION 6

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Needs: SECTION 7

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Strengths SECTION 8

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Client’s Strengths:

Recommendations:

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Print Client Name *

First

Last

Signature Date

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Printed Name of Case Manager *

First

Last

Signature Date