LIFESAVERS CARE SERVICES INTAKE FORM

Client Intake Form

Complete this intake form to request housing, support services, and/or placement review. Please answer all applicable questions accurately and provide any additional details that may help with assessment and coordination.
Client Information
Date of Intake

MonthDayYear
Date
Referral Source
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Preferred Name
Government ID Number
Type of ID (above)
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Living Situation
What is current living situation:

Other
Other (explain)
Desired Move-In Date (if applicable)

MonthDayYear
Date
Requested Service Start Date (if applicable)

MonthDayYear
Date
Hour MinutesAM/PM Option
Referral Information
Referred by:
example@example.com
Organization (if applicable):
example@example.com
Phone/Email:
example@example.com
Military and VA Information
Branch of Service

Other
Service Dates
Discharge Status
VA Enrolled
VA ID Number
VA Case Manager Name
VA Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
VA Case Manager Email
example@example.com
Authorization Number
Housing and Service Needs
Housing Need / Reason for Referral (check all that apply)

Other
Housing Need - Other
Describe current situation / need
Functional Support Needs

Other
Functional Support Needs - Other
Primary Needs
Medical & Care Infomation
Primary Diagnosis:
Secondary Conditions:
Allergies
Medication List
Mobility Status
Fall Risk
Current Hospice Services
If yes, hospice provider
Behavioral / Safety Concerns to be aware of
Is the client currently receiving:
Cognitive Status:
Other (explain)
Any behaviors to be aware of:
Other (explain)
Preferred Care Level:
Safety Concerns
Are there safety concerns?
Other (explain)
Schedule of Care
Days Needed:
Shift Type:
Substance Use and Recovery
Current or Past Substance Use

Other
Narcan trained / needs Narcan education
Tobacco use / smoking needs
Substance Use - Other
Current Status (Substance Use)

Other
Date of Last Use

MonthDayYear
Date
Currently enrolled in treatment/support

Other
Currently enrolled in treatment/support - Other
Current recovery supports
History of overdose or withdrawal requiring medical care
If yes, explain
Triggers / relapse risks / supports we should know
Need recovery-focused housing environment
Legal, Supervision, and Reentry
Currently on supervision

Other
Supervision - Other
Case worker / probation officer name
Case worker / probation officer Phone / Email
Any active warrants or pending charges
History that may affect housing placement or safety planning

Other
History affecting housing - Other
Registered offender restrictions impacting housing location
Court dates or legal appointments needing transportation support
Reentry goals / supports needed

Other
Reentry goals - Other
Curfew or supervision needs
Roommate compatibility concerns
Financial, Room, Transportation, Goals, and Documents
Income / Payment Source

Other
Income / Payment Source - Other
Monthly Income
Room Preference
Transportation Needs

Other
Transportation Needs - Other
Personal Goals

Other
Personal Goals - Other
Documents Available (check all that apply)

Other
Documents Requested - Other
Notes
Consent to Contact & Services - Signatures

I authorize Lifesavers Support Services LLC to contact me regarding services and understand that services provided are non-medical in nature.
Client / Representative Signature
Client / Representative Signature Date

MonthDayYear
Date
Intake Decision (for Administration use only)
Intake Completed By
Should be Empty:

Client Intake Form

Client Information

Living Situation

Referral Information

Military and VA Information

Housing and Service Needs

Medical & Care Infomation

Safety Concerns

Schedule of Care

Substance Use and Recovery

Legal, Supervision, and Reentry

Financial, Room, Transportation, Goals, and Documents

Consent to Contact & Services - Signatures