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INDIVIDUAL AND FAMILY ASSESSMENT

Intake Checklist

Copyright 2003-2005 Roger N. Meyer

All Rights Reserved

 

This list is a guide and focus tool for human service professionals conducting an initial or follow-up case intake visit in person with persons having cognitive disabilities and/or autism spectrum disorder (ASD).

 

Individual's name______________________________     Intake Date_________

 

Age/Status

____Child/adolescent

____Adult

 

____Public Assistance History:  GA; AFDC (or current equivalent); Food Stamps; Section 8 or other housing assistance; post-incarceration

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Continue notes on separate page

 

School History

____Standard diploma/diploma track K-12

____Special education/section 504 K-12 student

____GED or other equivalency

____Community college

____Bachelor's level undergraduate degree completed

____Graduate/Professional Education (State degree if attained______________

____Vocational, apprenticeship, trade training ___________________________

____Other training and education______________________________________

 

Special Education History

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

Continue notes on separate page

 

Living Independently? (Describe conditions to include housing, housing history, degree of habilitation care if  care if supported)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Continue notes on separate page

 

____Financial management issues, including debt, allowance, wages, salary, benefits, trust fund income, occasional or regular support by others

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Continue notes on separate page

 

____Medical insurance, dental, physical condition history, medications past and present, medication management, hospitalization history, current occasional or regular support by others, drug/alcohol history, sleep disorders, seizure history

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Continuation notes on separate page

 

____Alcohol, Drug, Abusive Behavior History  Includes arrests, TRO's, incarceration, criminal history including all charges, plea reductions, probation and/or parole history

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Continuation notes on separate page

 

____Psychological/MH history include all diagnoses or "labels" provided by others, pharmaceuticals, hospitalization, clinic, therapy/counseling past and/or pres_____________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Continuation notes on separate page

 

____Family of origin intact marriage, blended, siblings, raised by single parent, suggestion of same or related condition in primary family members, MH issues in biological or step parents/siblings

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Continuation notes on separate page

 

____Friendship history, past intimate relationships _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Continuation notes on separate page

 

____Current family relationships/setting_____________________________

 ______________________________________________________________

_______________________________________________________________

Continuation notes on separate page

 

____Employment history/current employment status ________________________________________________________________

________________________________________________________________

________________________________________________________________

Continuation notes on separate page

 ____Adult agency history past/current DD, VR, public housing or supported housing, brokerage services, supported employment, day activities programs __________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Continuation notes on separate page

 ____Competency issues capacity to sign agreement to represent __________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Continuation notes on separate page

 

Adult Functional  (for self-reporting of satisfaction, use scale of 1-10 from least able/dissatisfied to most able/satisfied)

 

____Transportation (driving, public transportation, mobility issues)

____Habilitation (care and maintenance of residence)

____Employability

____Leisure and recreation

____Special interests

____Hobbies

____Physical conditioning and exercise

____Personal care

____Shopping

____Communication with others (phone; Internet)

____Isolation v. social involvement (differentiate loneliness from satisfaction in being alone)

____Religious/church/spiritual involvement

____Control over scheduling, time management

____Making/keeping appointments

____Ability to locate and use needed resources

____Attention span/distractibility

____Self-identified special persons

____Self-description of mood, mood cycles

____Mood lability reported by others

____Self-reporting coherency (general)

____Self-reported history coherency

____Eye contact

____Speech (fluency, prosody, reciprocity, monologues)

____"Logic system"

____Problem-solving ability (be specific; start with self-reported challenges)

____Self-rated self-esteem

____Perseverations, fantasies, rumination

____Generalized awareness of others: intent, needs, boundaries

____Self-report about temper, anger, outbursts

____Sense of independence and control over life

____If diagnosed, extent of self-determination from denial to understanding (rank 1-5)

____Informal assessment of follow-up ability (rank from 1-5 none to high)

____Subjective assessment of truthfulness (rank from frank [1] to evasive [5]

 

____Records Elsewhere:  Medical, psychological, educational, training programs, housing, VR and other employment readiness or vocational training, family records with relatives (who), protective services, juvenile or adult justice system, volunteer agencies, past employers, adoption or foster placement agencies, military, VA, arrest/conviction rap sheets, diversion programs, detox programs, public housing, religious/homeless service agencies, hospitals and clinics (transient or single-time use), civil suit records, employment agencies, state employment/unemployment insurance, medical or other insurance plan records, closed or expunged conviction records, legal or other records protected by professional privilege

 

____Self-Reported and Self-Ranked Priorities/Needs (No more than 5):

_______________Notes

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

For additional notes, use a separate sheet

 

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