Youth Consultation Service

Client’s Name ______Date ______

Shelter Intake Assessment Form

Identifying Information

YCS ID Code/CMHC number ______Admission Date: ______

Client Name: ______Intake Date: ______

Client Nickname: ______

Date of Birth ______Age ______Gender ______

Medicaid Number ______K C Number ______

Social Security Number ______- __ __ - ______

Admitted from: ______Contact: ______Phone #______

Referred by: ______Agency: ______Phone #______

Parent/Legal Guardian ______

Address ______

City ______State ______Zip Code ______

Home Phone ______Work Phone ______

Emergency Number ______Contact Person ______

Address: ______

Caretaker: ______Phone Number ______

Relationship to client: ______Address: ______

Person (and relationship) who brought the client to the shelter ______

Address: ______Phone Number: ______

Approved Visitors/Contacts

Approved Visitor/Contact Relationship Telephone Number Approved By

______

Contact Restrictions: ______

Presenting Situation

Potential for self harm: ______Potential for harm to others: ______

Precipitating Event/Reason for Shelter Placement: ______

______

Current behavioral/emotional issues:______

______

Current Medications: ______

______

History of presenting problem ______

______

History of prior treatment attempts to address the problem described above: ______

______

Gang involvement: ______

Treatment History

Previous Admissions and placements: ______

______

History of Psychotropic Medications: ______

______

History of Psychiatric Hospitalizations (location, date, reason) ______

______

Current Providers (including DYFS, DDD, CMO, Case Management)

Placing agency (if any): ______

Contact______Agency______

Address (optional)______

Phone ______Service Provided ______

Contact______Agency______

Address (optional) ______

Phone ______Service Provided ______

Family Information

Family Members (include biological, adoptive, foster, treatment, etc)

List Family Members (including siblings), Relationship, Age, Gender (include if the client has a child)

______

Describe current family involvement

______

Substance Abuse /Addictions History (Fill in the blank with the age of onset, if applicable.)

Alcohol _____ Heroin ____ Other ____

Tobacco _____ Amphetamines ____

Marijuana _____ Barbiturates ____

Cocaine _____ Gambling ____

Other pertinent information: ______

______

Medical History

ALLERGIES: (food, medication, environment) ______

Chronic conditions: ______

Past serious illness: ______

Special Diet: ______

Physician’s name and phone number: ______

Please describe any interaction between medical conditions and psychiatric status. (Example: noncompliant diabetic who has erratic behavior when the blood sugar is low and is aggressive when the blood sugar is high.) ______

______

A detailed medical history and evaluation will be completed by health services.

Sexual History

Client is sexually active: YES ______NO ______

Client’s sexual orientation: Heterosexual___ Gay ______Lesbian_____Bi-sexual____

Transgendered ____ Client is unsure ______

History of Victimization: YES ______NO ______

History of being a Predator: YES ______NO ______

Other Notable Issues: ______

______

Activities of Daily Living

Comment on the child’s functioning if NOT appropriate to their age with regard to the following areas:

Hygiene, transportation, money management, home care, chores/willingness to help, ability to dress

______

Culture/Religion

Race ______Ethnicity ______

Religion ______Place of Birth: ______

Language of Upbringing: ______Language which consumer prefers: ______

Important cultural/religious celebrations for the client ______

Other cultural concerns ______

______

Legal Factors

Legal issues/status ______

______

Probation Officer: ______Telephone Number: ______

Educational/Vocational Information

Most Recent School Attended ______

Grade______Classification: ______

School Phone ______Contact person: ______

Copy of IEP obtained: ____Yes _____No Employer (if any): ______

Intake Assessment participants:

______

DYFS Case Worker Print Sign Date

______

YCS Supervisor Print Sign Date

______

Client Print Sign Date

______

Parent/Guardian Print Sign Date

______

YCS Case Manager Print Sign Date

______

Nurse Print Sign Date

______

Other Print Sign Date

Shelter Service Plan (3-5 Days)

Upon review of the information in this assessment, and any other assessment information available (such as medical), create a service plan for the client that will:

1. Support their adjustment to the shelter.

2. Address immediate emotional, behavioral and medical needs.

3. Maintain involvement with family, school and community resources.

4. Assist in planning for their return home or placement in a more permanent setting

(Minimum of three goals)

1. Goal #1: ______