Client Screening Checklist
Gather essential information for client placement and support.
Agency Information
Provide details about your agency and the case manager.
Agency Name
*
Case Manager Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Client Basic Information
Provide the client's basic details.
Client Name
*
Age
*
Gender
*
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Expected Move-In Date
-
Month
-
Day
Year
Date
Reason for Referral
*
Why is the client leaving their current placement?
Has the client lived in independent living before?
*
Yes
No
Mental Health / Medical
Information about mental health and medical status.
Does the client have a mental health diagnosis?
*
Yes
No
If yes, what is the diagnosis?
Is the client currently stable?
*
Yes
No
Are they connected to a therapist or case manager?
*
Yes
No
Medication
Medication management and independence.
Does the client take medication?
*
Yes
No
Can the client manage their medication independently?
*
Yes
No
Level of Independence
Daily living skills assessment.
Can the client cook for themselves?
*
Yes
No
Can the client clean their living space?
*
Yes
No
Can the client maintain personal hygiene?
*
Yes
No
Can the client live in a shared home environment?
*
Yes
No
Income / Payment Source
Select all sources of income or payment.
Income / Payment Source
*
SSI / SSDI
Private Pay
Agency Placement
Voucher Program
Other
Amount per month (if known)
Behavioral / Safety History
Assess behavioral and safety risks.
Any history of violence or aggression?
*
Yes
No
Any recent psychiatric hospitalizations?
*
Yes
No
Any substance abuse concerns?
*
Yes
No
Background Considerations
Legal or background issues that may affect placement.
Any criminal background that would affect housing placement?
*
Yes
No
If yes, please explain
Support Services
Information about outside services the client receives.
Does the client receive outside services?
*
Yes
No
Services include (select all that apply):
Case Management
Therapy
Job Support
Other
Emergency Contact
Provide an emergency contact for the client.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Client
*
Additional Notes
Submit
Should be Empty: