TM2K Client Intake Form | Team Management 2000, Inc.

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Client Face Sheet

Page 1 — Demographics & Contact Information

Intake Date *

CHAMP ID

Last Name *

First Name *

M.I.

Social Security #

Date of Birth *

Gender

Male Female

Address

Apt

City

State

Zip

Home Telephone

Cell Phone

Emergency Contact Name

Emergency Contact Phone

Relationship to Client

Race/Ethnicity

Referral Source

Agency Name/Contact

Form Completed By (Staff Name & Title)

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Ryan White Reassessment

Page 2 — Client Status & Baseline Information

Client Status

Active Inactive

Status Date

Sexual Orientation

Homosexual Heterosexual Bisexual Unknown

HIV Status

HIV Positive AIDS Status Unknown

Year Confirming HIV Status

HIV/AIDS Diagnosis Location

HIV Exposure

Employment Status

Caregiver Support

Medically Unable to Work?

Yes No Don't Know

Income Source

Annual Income

Family Size

Living In

Private Home Apartment Shelter

Pay Source

Usual Source of Primary Care

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Biopsychosocial Assessment

Pages 3-5 — Chief Complaint, Risk, & History

Emergency Condition Found?

Yes No

If yes, what steps taken?

Chief Complaint (in consumer's own words)

Danger to Self?

Yes No

Danger to Others?

Yes No

Self-Mutilating Behavior?

Yes No

Marital/Relationship Status & Sexual History

Family History / Housing

History of Abuse?

Yes No

If yes, explain

Family Psychiatric History (1st degree relatives)

Educational History

Vocational History (including military)

Financial Status (income, insurance)

Legal History (probation, charges, warrants)

Medical History

Current Medications

Previous/Present Case Management Services

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Mental Status Examination

Page 7 — Appearance, Behavior & Cognitive Function

Appearance

Behavior

Speech (Rate/Tone)

Goal Directed?

Yes No

Suicidal?

Yes No

Homicidal?

Yes No

Hallucinations?

Yes No

Level of Consciousness

Alert Drowsy Lethargic Stuporous

Intellectual Functioning

Retarded Below Avg Average Above Avg Superior

Insight

Good Fair Poor

Judgment

Good Fair Poor

Strengths / Assets

Problems / Needs

Physical/Social Barriers to Services

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Summary & Diagnosis

Page 8 — Clinical Summary, Dental/Nutrition, and Diagnosis

Clinical Summary (Problems/Needs)

Seeing Dental Provider?

Yes No

Dentist Name/Contact

Need Dental Referral?

Yes No

Eating Regularly?

Yes No

Meals/Day

Receive Food Stamps?

Yes No

AXIS I

DSM-IV Code

AXIS II

DSM-IV Code

AXIS III

AXIS IV

AXIS V (Current)

Highest Past Year

Treatment Recommendations

Reassessment Date

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Service Plan

Page 12 — Goals, Action Steps & Signatures

Needs Assessment — Living Arrangement

Lack of Housing Inadequate Housing Other

Needs Assessment — Medical

Initiate Care Keeping Appts TX Education Nutrition Other

Needs Assessment — Support

Mental Health Family/Child Partner Support Group Other

Short-Term Goals (1-3 months)

Long-Term Goals (3-9 months)

Client Action Steps

Client Target Date

Date Completed

Staff Action Steps

Staff Target Date

Date Completed

What Barriers Does the Client Anticipate?

Reassessment Date

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Signatures

Client & Staff Signatures

Client Signature

Date

Staff Signature

Date

Supervisor Signature (if required)

Date