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Case Management Intake Assessment Form Sample

Other (Not Listed) Instructions:

During the initial meeting with the client the case manager will gather information to address the client's immediate needs to encourage his/her engagement and retention in services. Pertinent information is reflected in the intake form.
The intake form used during the initial meeting may also be used to screen clients to determine if they need case management services.
The Comprehensive Intake Form is due APRIL 12th. You may submit this form, following the instructions below, anytime after reading chapters 14, 15,16 and 18. The form is located in the class material tab.
Instructions:
1) Resource: Read chapters 14, 15, 16 and 18 Fundamentals of Case Mgmt Practice Edition: 5th
Author: Nancy Summers Publisher: Cengage Learning
2) Read the intake form
3) Watch the video below (cut and paste link) and complete the intake form
https://www(dot)youtube(dot)com/watch?v=3QFD60L20xA
IMPORTANT: In order to submit a complete, accurate and concise intake you must READ the chapters before completing the intake form. Remember ALL spaces must be completed in the form.
Client info for your intake:
The client was born September 15, 1952. The counseling session takes place 15 days after his birthday. Wildwood Case Management Unit
Intake Assessment Form
Client Name: 
D.O.B 
Date of Assessment 
PRESENTING PROBLEM (Functional impairment, symptoms, background)
CURRENT CLIENT INVOLVEMENT WITH OTHER AGENCIES 
ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
Family
Social
Support 
Legal
Education
Occupation 
Finances 
Psychosocial and environmental problems 
CURRENT MEDICAL CONDITIONS 
PREGNANT ( ) YES ( )NO
Receiving prenatal care? ( )YES ( )NO 
PRIMARY CARE PHYSICIAN 
CURRENT MEDICATIONS
Name/Dosage Prescribed By Condition 
Side Effects 
Medication Allergies 
RELATIONSHIP RISK FACTORS 
Is client safe at home? ( ) YES ( )NO 
Does client feel threatened in any way? ( )YES ( ) NO

Other (Not Listed) Sample Content Preview:
Wildwood Case Management Unit
Intake Assessment Form
Client Name: Rick
D.O.B September 15, 1952.
Date of Assessment 31/8/2012
PRESENTING PROBLEM (Functional impairment, symptoms, background)
Rick was referred for treatment by his wife. He has been experiencing stress following the loss of his job. He is worried on how to support his family without a job. Rick has a history of alcohol abuse and because he is jobless his drinking habits have increased. With his age, he is worried that getting another job might be futile to him.
CURRENT CLIENT INVOLVEMENT WITH OTHER AGENCIES
N/A
ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
Family
He is the Head of his household at the time of referral. Rick is 59 years and has been married for 40 years; he has three children
Social
Alienated from friends
Support
Currently Rick is supported by his wife
Legal
N/A
Education
N/A
Occupation
N/A
Finances
Mr. Rick experiences financial problems
Psychosocial and environmental problems
Alcohol abuse
Unemployment
He believes that his new boss does not like him and that is why he laid him off
CURRENT MEDICAL CONDITIONS
N/A
PREGNANT ( ) YES(●) NO
Receiving prenatal care? ( ) YES (●) NO
PRIMARY CARE PHYSICIAN
N/A
CURRENT MEDICATIONS
Name/DosageN/APrescribed ByN/ACondition
N/A
Side Effects
N/A
Medication Allergies
N/A
RELATIONSHIP RISK FACTORS
Is client safe at home? (● ) YES ( ) NO
Does client feel threatened in any way?() YES (●) NO
If YES describe
________ N/A _____________________________________________________________
Has client been abused in any way? ( ) YES (●) NO
If yes check all that apply
( ) Physical ( ) Emotional ( ) Sexual
Relationship of perpetrator to client
________ N/A ____________________________________________________
Any legal action taken?
________ N/A ______________________________________________________________
Does client have a safety plan? ( ) YES (●) NO
Needs shelter ( ) YES(●) NO
Needs protection from abuse order( ) YES(●) NO
SUICIDE/HOMICIDE EVALUATION
(1-none 2-slight 3-moderate 4-extreme/immediate)
Client’s self-rating of suicide risk 1
Client’s self-rating of becoming violent2
Client’s self-rating of homicide risk 1
MENTAL STATUS EXAM
Appearance
( ) age appropriate (●) well groomed ( ) disheveled/unkempt ( ) bizarre ( ) other
Orientation
( ) person ( ) place ( ) time ( ) situation
Behavior/Eye Contact
(●) good( ) l limited ( ) avoidant ( ) relaxed/calm( ) restless( ) rigid
( ) agitated(●) slumped posture ( ) tense( ) tics( ) tremors
Motor Activity
(●) mannerisms( ) motor retardation ( ) catatonic behavior
Manner
() appropriate (●) trusting (●) cooperative ( ) inappropriate ( ) withdrawn
( ) seductive ( ) playful ( ) evasive( ) guarded( ) sullen ( ) passive
(●) defensive ( ) hostile ( ) maniac ( ) demanding ( )...
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