• Client Screening Checklist

    Gather essential information for client placement and support.

  • Agency Information

    Provide details about your agency and the case manager.
  • Format: (000) 000-0000.

  • Client Basic Information

    Provide the client's basic details.
  • Expected Move-In Date
     - -
  • Has the client lived in independent living before?*

  • Mental Health / Medical

    Information about mental health and medical status.
  • Does the client have a mental health diagnosis?*
  • Is the client currently stable?*
  • Are they connected to a therapist or case manager?*

  • Medication

    Medication management and independence.
  • Does the client take medication?*
  • Can the client manage their medication independently?*

  • Level of Independence

    Daily living skills assessment.
  • Can the client cook for themselves?*
  • Can the client clean their living space?*
  • Can the client maintain personal hygiene?*
  • Can the client live in a shared home environment?*

  • Income / Payment Source

    Select all sources of income or payment.
  • Income / Payment Source*

  • Behavioral / Safety History

    Assess behavioral and safety risks.
  • Any history of violence or aggression?*
  • Any recent psychiatric hospitalizations?*
  • Any substance abuse concerns?*

  • Background Considerations

    Legal or background issues that may affect placement.
  • Any criminal background that would affect housing placement?*

  • Support Services

    Information about outside services the client receives.
  • Does the client receive outside services?*
  • Services include (select all that apply):

  • Emergency Contact

    Provide an emergency contact for the client.
  • Format: (000) 000-0000.
  • Should be Empty: