Case Management Intake Form

Collects a new client's personal, medical, and social details to build a tailored case management plan.

Use this template

Date of Intake

Case Number

Client Name

Nombre

Apellido

Date of Birth

Gender

Male Female Other Prefer not to say

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Emergency Contact Name

Nombre

Apellido

Relationship

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Referred By

Nombre

Apellido

Organization

Phone Number

Reason for Referral

Please describe the main issues or problems you are experiencing

How long have you been experiencing these issues?

Have you sought help for these issues before?

Yes No

If yes, please provide details

Physician's Name

Nombre

Apellido

Phone Number

Current Medications

Allergies

Medical Conditions

Mental Health History

Children

Yes No

If yes, please list their ages and any relevant information

Living Situation

Lives alone Lives with family Lives with roommates Assisted living Shelter

Current Employment Status

Occupation

Employer

Highest Level of Education

Primary school Secondary school High school Associate degree Bachelor's degree Graduate degree

Source of Income

Monthly Income

Monthly Expenses

What are your goals for seeking case management services?

What outcomes are you hoping to achieve?

Is there anything else you would like us to know?

Intake Officer's Name

Nombre

Apellido

Signature

Sign here

Client's Name

Nombre

Apellido

Signature

Sign here

Date

Case Management Intake Form

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