Client Intake Form

Client Intake Form
Date

MonthDayYear
Date
Primary contact person

First NameLast Name
How do you know the client?
If you are a legal guardian, you understand and agree to being present in all the client meetings and registered cases .
- Client Name
  
  First NameLast Name
- Client Birthday Date
  
  MonthDayYear
  Date
- Client Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Best e-mail address to receive messages and appointment confirmations
  example@example.com
- Please list the client's diagnoses.
  All information is confidential and not shared with any outside agencies or individual persons.
- File Upload
  
  Please upload any IEPs, education plans, psychological, or medical diagnosis paperwork. The more information the better. If you are working with specialists such as speech or behavioral therapy, please feel free to include for the client's file.
  Cancelof
- Does the client take daily medications?
- If you answered yes to the previous question, is the client able to administer their own medications without assistance or prompting from another adult?
- Is the client on a parent's/legal guardian's insurance plan?
- Is the client actively participating in Vocational Rehabilitation activities?
- Is the client a member of the Agency of Persons with Disabilities?
- Does the client receive SSI?
- Does the client receive SSDI?
- Will the client apply (or is already receiving) for food stamps, WIC, or TANF?
- By signing this document, I understand payment is due before or at the transition planning and workforce readiness coaching service. I may pay via cash, check, Venmo, or PayPal.
  
  If I am on a payment plan, the first month is due at the time of the scheduled service.
  
  I understand I will receive information about local resources and suggested next steps to prepare the client for transition into adulthood/workplace.
  
  Any recommendations I receive do not replace medical, educational, or financial advice.
- Signature
- Should be Empty: