Little Hands and Creations (Intake Form)

Little Hands and Creations (Intake Form)
Intake Date:

MonthDayYear
Date
Discharge Date:

MonthDayYear
Date
Behavioral Assistant, Tutor, Mentor, and Intensive-In Community
Client Name:
DOB:
Client Phone:
Program Name:
Staff: Print Name

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Program Name:
Client Address:
Parent/Guardian:
LHC Staff Name: Agency: Care Manager:
Agency:
Position: Supervisor:
Position:
Supervisor:
Referring Authority: Perform Care Referring Authority
Part 1. Is DCPP (DIvision of Child protection & Permanency) Involved? Yes or No
Caseworker:
Local office:
Phone:
PART 2: Education ( In school, dropped out, Graduated)
School Name:
School Contact:
School Address:
Grade Attending
Type of School (public, private, special ed)
School Days Attended
Unexcused Absences
In-School Suspensions
Suspensions
Grade Point Average
ACTIVITIES: 1yr Prior entry
At Entry (now)
At Discharge
1. Felony (e.g. Murder, arson, etc
2. Felony Convictions (# of convictions)
3. Misdemeanor Arrests
4. Misdemeanor Convictions (# convictions)
5. Summary Convictions (# convictions)
6. Runaway Record (# of runaway events)
1. Living Arrangements (Independent, Home, Relative, Foster, Group, Hospital, Residential, Detention, Correctional)
1. Living Arrangements
2. Status of Home Environment (Improving, Stable, Unstable, and Deteriorating)
(Improving, Stable, Unstable, and Deteriorating)
3. Placement Risk (No Risk if at home)
(Low Risk- if in group home)- Medium/High Risk-if in residential/jail)
1. Treatment Programs (i.e. alcohol/drug)
2. Meetings Per week
3. Drug Abuse
4. Alcohol Abuse
1. Diagnosis (DSM 5)
2. Medication
3. Mental Health Hospitalizations or Crisis Encounters
Signature Parent/Guardian

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