C.A.R.E.S Residential Program for Youth Intake Form

EL Shama Cares Foundation Inc. Youth Intake and Risk Assessment Form

This form is also used for warming centers
Youth Name
Preferred Name
Date of Birth

MonthDayYear
Date
Gender Identity
CulturalHeritage Background
Primary Language
Date of Intake

MonthDayYear
Date
Referred By
Legal Status eg under guardianship temporary care
SECTION B: Placement Readiness - SELECT ALL THAT APPLIES
1. Behavioral Assessment

No behavioral concerns notedOccasionalemotional dysregulation or defianceHistoryof aggression toward peers or staffEngagesin self-harm or has suicidal ideation (non-acute)Engagesin self-harm or has suicidal ideation (acute)Displayssexualized behavior inappropriate to ageHistoryof substance use or experimentationPriorpolice involvement or probationDisplaysrespectful behavior and emotional controlOther
CommentsDetails
2. Life Skills Competence

Evaluate the youth's ability in the following areas:

Rows	INDEPENDENT	NEED REMINDERS	NEEDS EXTRA REMINDERS	NEEDS TO BE TAUGHT/EXTRA SUPPORT
Personal Hygiene
Cleanliness
Responsiveness
Cleaning/Room Maintenance
Cooking/Snack Preparation
Time Management
Academic EngagemenT

Comments Strengths
3. Emotional & Mental Health
SLECT ALL THAT APPLIES

Noconcerns at this timeMildanxiety or mood challengesDiagnosed mental health disorderTrauma-relatedbehaviors presentCurrently under mental health support or therapyType option 5Has out burst/ however not at anyoneDisturbs the peace of others
Supports Currently in Place
SECTION C: Dependency and Support Needs

4. Adult Support Dependency Rate level of dependency on adult support:

Narrative Overview
5. Trauma & History
Does the youth have a known trauma history?

YESNO
Yes (briefly describe):
Has the youth experienced any of the following?

Physical abuseSexual abuseEmotionalabuseNeglectWitnessedviolenceLoss/grief
Cultural or Community Supports Requested
SECTION D: Risk Level Placement Recommendation
Based on your history of the youth, collateral calls, and personal interaction and assessment above, what category would you recommended placement tier:

Zero Risk – Independent, minimal behavioral concerns, emotionally stableLow Risk – Mild emotional/behavioral challenges, requires moderate supportMedium Risk – Behavioral/emotional concerns present, requires structured supportTop end of the Medium risk scale
Assessed by name and role
Date

MonthDayYear
Date
SECTION E: Additional Notes / Cultural Considerations Please describe any cultural, spiritual, or gender-based supports that would enhance this youth's care:
Please describe any cultural spiritual or genderbased supports that would enhance this youths care
Should be Empty:

EL Shama Cares Foundation Inc. Youth Intake and Risk Assessment Form