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Intake Checklist
Client Information
Full name
Date of birth
Contact information (phone number, email)
Address
Preferred method of communication
Referral Source
Name of referring individual or organization
Reason for referral
Date of referral
Service Needs
Description of services requested
Goals for services
Urgency of needs
Any previous services received
Documentation
Identification (e.g., driver’s license, passport)
Insurance information (if applicable)
Consent forms
Any relevant medical or psychological records
Financial Information
Income source and amount
Employment status
Current financial obligations
Any available financial assistance programs
Risk Assessment
Any immediate safety concerns
History of self-harm or harm to others
Substance use history
Mental health history
Next Steps
Schedule initial appointment
Assign case manager or point of contact
Provide client with information about services
Follow-up plan and timeline
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