M_Group_Alabama_Intake_Form_COMPLETE

Intake Service Request
Start Date for Services*

MonthDayYear
Date
End Date for Services*

MonthDayYear
Date
County Name*
Client Case*
Dhr Supervisor Name*
DHR Supervisor Phone / Email*

Phone NumberEmail
Social worker/Case Manager Name:*
After Hours Phone Number *
Social Worker/Case Manager (Phone & Email)*
example@example.com
Child's Name:*
List all children here
Child's Date of Birth*
List each child's birthday
Place of Service List one of the following: *
School, DHR, Hospital, Foster Parent Home, Facility, Group Home, or Other
Service Address*
Service Phone Number*
Format: (000) 000-0000.
Primary Point of Contact (Name & Role/Title)*
Point of Contact Phone Email*
Format: (000) 000-0000.
Reason for Agency Involvement*
Please be very Detailed
Individual CounselingFamily Counseling (with child)Family Counseling (without child)Play TherapyTherapeutic Visitation (Hours requested: ___ / ___ )Emergency TransportationBehavioral AideIntensive In-Home ServicesBasic Living SkillsFamily Support (Individual/Group)Crisis InterventionMentoringDomestic Violence CoursesParenting CoursesAnger Management CoursesSitter ServicesBilingual Family Service Worker Needed
Details Regarding Services*
List behaviors, triggers, do's, don'ts, what to look out for, restrictions, safety concerns, etc.
Dates and Times of Service & Service Details Include days of week, start/end times, location notes, transportation/pickup requirements (if any), and any special instructions.
Dates and Times of Service Service Details*
Authorization / Requestor Information
Requestor Name Title*
Requestor Phone / Email*
Format: (000) 000-0000.
Signature*

Clear
Date*

MonthDayYear
Date
Additional Notes*
Should be Empty: