R. Interagency Client Intake Form Template

INTERAGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

Office Use Only

SOCIO-DEMOGRAPHIC HISTORY

Last Name First Name and Initial Sex

Maiden Name Alias/nickname Name(s) (D.O.B.) MM DD YY

Health Card. Number 10 digit Band Number First Nation, Inuit, Métis

Reserve Location of Reserve (Region / Province)

Address:

Apt #/ Number & Street City / Town / Reserve Province Postal Code

Phone (home) Phone (work) Phone (cell)

Family / Regular Physician Phone Number

1
2

Emergency Contacts Relationship Phone(day) Phone(other)

INTERAGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

Client Services Required*** Please check any services you may be interested in ***

Spiritual
⁪ Traditional Healer
Spiritual Help
⁪ Ceremonies
⁪ Sweat Lodge
⁪ Sharing / Teaching Circle
⁪ Clan / Colours / Name
⁪ Smudging
Emotional
⁪ Counselling
Sexual Assault Services
⁪ Stress / Anger Management
⁪ Traditional Family Counselling
⁪ Addictions Treatment
⁪ Residential School Survivors
⁪ 12 step Program / / Mental
⁪ Traditional Counselling
⁪ Psychiatric / Psychologist
⁪ Training Program
Mental Health Services
⁪ FASD Program
⁪ Red Road Recovery
Self Help Groups
⁪
Physical
⁪ Housing / Shelter
⁪ Traditional Medicine
⁪ Healthy Lifestyles
Recreation
⁪
⁪
⁪

Client Concerns:

AGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

CULTURAL BACKGROUND

Spiritual Beliefs: / Traditional / Roman Catholic
Anglican / Pentecostal
Other-
Clan / Name / Colours

MARITAL STATUS

Single / Married / Common-law
Divorced / Separated / Widow
Single Parent

LIVING ARRANGEMENT

With Parents / Children / Friends
Spouse & Children / Relatives / Shelter
Spouse / Alone / Other-

LANGUAGES SPOKEN

Algonquin / Cayuga / East/West / Dakota/Siouan / Western
Ojibway / Mohawk / Micmac / Assiniboine / English
Cree / Oneida / Montagnais / Lakota / French
Oji-Cree / Tuscarora / Blackfoot / Dakota
Odawa / Onondaga / Dene / Fox
Pottawatomie / Seneca / Haida
Salteaux / Shushwap
Other-

INTERAGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

EDUCATION BACKGROUND

Please state your level and/ or grade of completion:

Elementary (grade completed) / High School (grade completed
College diploma (program course)
University degree (program course)
Other Courses/Training:

EMPLOYMENT

Part-time / Homemaker / Self-Employed / Job Training
Employed / Unemployed / Seasonal / Retired
Student / E.I. / Temporary / Other-

INCOME SOURCE

Job / Income Assistance / Family
E.I. / None / Other-

LEGAL STATUS

Parole -Current Parole condition:
Probation -Current Parole condition
Incarcerated –Release date:
Court/Legal Action Pending:
Court Date:
Current Charges:
Outstanding charges:
Prior Charges:

INTERAGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

PRESENT STRENGTHS

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2.
3.
4.
5.
6.
7.

TRAUMA HISTORY

History of Suicide/Ideation
History of Sexual Victimization
Family Violence
Family Addiction (Substance & Gaming)
Residential School
Prior treatment x number
Detoxification treatment attended
Learning/Language Challenges
ð Reading ð Writing ð Math

OTHER PRESENTING ISSUES

Anger Issues (loss, guilt, shame)
Physical Impairment
Developmental Delay
Education/Training
Housing
Financial
Mental Health
Other-

INTERAGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

ADDICTION DEPENDENCY

In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)

Addiction dependency / Yes / No / No Answer / Length of Time (years)
Solvents ____number of times sniffs per day (gasoline, glue, propane)
Beer ____number of standard drinks in a week
Liquor ____number of standard drinks in a week (purchased/ home brew)
Cigarettes ____number of packs per day
Marijuana ____number of joints per day (pot, hash, oil)
Prescription drugs ____number of pills per day
Cocaine ___number of hits per day
Crack/hash ____ number of pipes or bowls per day
1 standard drink=13.6 grams of alcohol
=1.5 oz/43 ml of spirits (40% alcohol)
=2 oz/341 ml of regular strength beer (5% alcohol)
Higher alcohol beers and coolers have more alcohol than one standard drink.

AGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

TYPE of DRUG ADDICTION

In the past year, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)

Yes / No / No answer / Length of time
Years
CANNABIS hash, weed, grass, pot, marijuana
AMPHETAMINES / OTHER STIMULANTS
(Speed, diet pills, ecstasy, etc.)
BENZODIAZEPINES
(sleeping pills, tranquillizers-Xanax, Ativan, Valium and Klonipin)
BARBITURATES
(sedative drugs, Sleeping Pills -Serepax)
COCAINE /CRACK (coke, crack)
HALLUCINOGENS
(LSD, magic mushrooms, acid)
HEROIN /OPIUM
(opiate derived)
OPIOIDS
(heroin, morphine, methadone, etc)
PSYCHOACTIVE DRUGS
(crystal meth)
OVER THE COUNTER
PREPARATIONS
(cough preps-codeine)
PRESCRIPTION
(Oxycotin, Vicodin, Percoset, Darvon, Morphine, Fentanyl )

INTERAGENCY CLIENT INTAKE FORM

Date of Intake Intake Staff Member Client No.

Counsellor’s estimate level of use reported:

Low: / Client is at low risk of health and other problems from their current pattern of use.
Moderate: / Client is at risk of health and other problems from their current pattern of substance use.
High: / Client is at high risk of experiencing severe problems (health, social, financial, legal, relationships) as a result of their current pattern of use and is likely to be substance dependent.

Client level of concern about present substance use:

How concerned are you about your substance use?
ð Low ð Moderate ð High

Complete observations, concerns and treatment plans on the TREATMENT PLAN form.

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