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.youtube.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