Community Rehabilitation Program Intake checklist
Personal Information
- Select the client's gender from the options provided.
- If the client's gender is not listed, provide an 'Other' option and allow for free text input.
- Enter the client's address, including street, city, state, and zip code.
- Enter the client's phone number.
- Enter the client's email address.
- Select the client's preferred method of communication from the options provided.
- If the client's preferred method is not listed, provide an 'Other' option and allow for free text input.
- Select the client's marital status from the options provided.
- If the client's marital status is not listed, provide an 'Other' option and allow for free text input.
- Select the client's ethnicity from the options provided.
- If the client's ethnicity is not listed, provide an 'Other' option and allow for free text input.
- Enter the name of the client's emergency contact.
- Enter the phone number of the client's emergency contact.
- Select the client's preferred pronouns from the options provided.
- If the client's preferred pronouns are not listed, provide an 'Other' option and allow for free text input.
- Select the client's language proficiency level from the options provided.
- If the client's language proficiency level is not listed, provide an 'Other' option and allow for free text input.
- Select the client's current living situation from the options provided.
- If the client's living situation is not listed, provide an 'Other' option and allow for free text input.
- Select the client's citizenship status from the options provided.
- If the client's citizenship status is not listed, provide an 'Other' option and allow for free text input.
Referral Information
Medical Information
- Name of primary care physician
- Contact information for primary care physician
- Health insurance provider
- Policy number
- Contact information for insurance provider
- Name of emergency contact
- Relationship to client
- Contact information for emergency contact
Employment History
- List all relevant skills and qualifications.
- Include any certifications or vocational training.
Use in Manifestly