COUNSELING INTAKE FORM
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Get it written →COUNSELING INTAKE FORM
Client’s Name__________________________________Age_________Date__________
Full Address___________________________________________________________
Home Phone__________________________ E-mail______________
Case Manager’s Name______________________________________
Date of Initial Contact __________
Reason for contact with client:
Important Medical Situations:
Family background. Include names and other information about any family or close friend. Relationship with these people?
Living arrangements. Describe the client’s living situation. Where does the client live? What type of facility does client live in? Describe lifestyle.
Economic Information. Amount of source of income and needs.
Background information. Place of birth, ethnic or cultural factors, education, and early history—anything that appears significant in view of the client’s current situation, human services planning, and educational planning.
Case manager’s impressions.
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