Client Intake and Eligibility Screening Form

Collects identifying information, household composition, income, presenting needs, and program eligibility for human services intake. Used by case managers at first contact to assess client needs and determine program eligibility.

Consent and Privacy Notice

• I have read and understand the Privacy Notice above
  You must acknowledge the privacy notice to proceed with this intake form.
• I consent to the collection and use of my personal information for the purpose of determining eligibility and receiving services from this agency
• I prefer to complete an anonymous needs assessment only (note: anonymous submissions cannot be used to enroll in specific programs)
  Selecting this option will limit which programs you can be enrolled in, but allows you to explore available services without providing identifying information.
• Intake Date
  Date this intake form is being completed.
• Intake Method
• Case Manager / Staff ID (if assisted intake)
  Enter the staff ID of the case manager completing this form on behalf of the client, if applicable.

Client Identifying Information

• First Name *
• Middle Name
• Last Name *
• Preferred Name or Nickname
• Date of Birth *
  Required for age-based program eligibility determination.
• Gender Identity
  Optional. Used for demographic reporting and to ensure appropriate service referrals.
• Primary Language *
  Used to arrange interpreter services if needed.
• Interpreter or Language Assistance Needed?
• Do you require any accessibility accommodations to participate in services? (ADA)
  Select all that apply. This agency provides reasonable accommodations under the Americans with Disabilities Act.

Contact and Address Information

• Current Housing Status *
• Current Address (Street, City, State, ZIP)
  If you do not have a stable address, leave blank or enter a shelter or service address.
• Mailing address is the same as current address
• Mailing Address (if different)
• Primary Phone Number
• Phone Type
• OK to leave a voicemail at this number?
• Email Address
  Optional. Used only for appointment reminders and service communications.
• Preferred Contact Method *

Household Composition

• Total Number of People in Household (including yourself) *
• Number of Children Under Age 18 in Household
• Number of Adults Age 60 or Older in Household
  Used to assess eligibility for senior services programs.
• Does the household include a pregnant or recently postpartum individual?
• Does the household include a U.S. military veteran?
  Veterans may qualify for additional benefits through VA and veteran-specific programs.
• Does any household member have a documented disability?
• Additional Household Notes (optional)

Income and Financial Information

• Total Estimated Monthly Gross Household Income (before taxes) *
  Enter 0 if currently no income. Include all household members' income combined.
• Sources of Household Income (select all that apply) *
• Is your household currently receiving any of the following benefits?
  Select all that apply. This helps avoid duplicate enrollment and identify gaps.
• Has your household experienced a significant change in income or financial situation in the past 90 days?
• Briefly describe the change

Presenting Needs and Service Request

• Primary Needs (select all that apply) *
• How urgent is your primary need? *
• Describe your current situation and what you are hoping to receive help with *
  Your response is confidential and used only by case managers assigned to your case.
• Are you or anyone in your household currently in a situation involving immediate safety concerns (e.g., domestic violence, threats, unsafe living conditions)?
  If yes, a case manager will prioritize your intake and connect you with safety resources. If you are in immediate danger, please call 911.
• Safety Concern Details (optional — only share what you are comfortable sharing)
• Have you previously received services from this agency or another social services organization?
• How did you hear about us or who referred you?

Program Eligibility Screening

• Current U.S. Residency / Immigration Status
  Some programs have federal residency requirements. This information is used only for eligibility determination and is not shared with immigration authorities.
• County of Current Residence *
  Required to confirm service area eligibility.
• How long have you lived in this county or service area?
• Which programs are you interested in applying for? (select all that apply)
  A case manager will confirm eligibility and assist with applications during your appointment.
• I authorize this agency to share relevant intake information with partner organizations for the purpose of coordinating services on my behalf
  You may limit or revoke this authorization at any time by contacting your case manager. Refusing does not affect your eligibility for services at this agency.

Case Manager Notes and Certification

• Case Manager Intake Assessment Notes
  For internal use only. Not visible to client.
• Assessed Risk Level
• Does this intake trigger a mandatory reporting obligation?
  Mandatory reporting may apply under state child abuse (e.g., CAPTA), elder abuse, or domestic violence statutes. Consult your supervisor if unsure.
• Programs / Services Referred at Intake
• Scheduled Follow-Up Date
• I certify that the information recorded in this intake form is accurate to the best of my knowledge and was collected in accordance with agency policy and applicable confidentiality requirements
• Case Manager Signature