INTAKE - ANNUAL - QUARTERLY STATUS/MEDICAL UPDATE	Date
Client	Meeting Date with Client
Staff	Meeting Date with WSC
Months Covered	Qtr 3/AR	Qtr 1	Qtr 2	Qtr 4/IP
STATUS UPDATE: Briefly explain any areas of importance to the individual, that have impacted the individual, or affected goal progress during this time. Ask the client to state what he knows/understands about each area. Explain how the client is empowered to make informed decisions about things that affect him (health, safety, rights, etc). Provide examples and use quotes if explanation is in the client's own words.
Intake with a new client?	Yes	No	Date of intake, if Yes.
Changes Needed?

General Well-Being

Incidents/Complaints/

Grievances
Strengths/Capabilities

Barriers/Challenges

Hobbies/Interests/

Projects
Achievements of Special Note
Major Life Changes

Needs

Participation in Activities (List)
Social Inclusion/Uses Environment
Safety Issues/Makes Informed Decisions
Health Issues/Makes Informed Decisions
Diet/Nutrition

Proper Administration of Medications
Adequate Medications (5 days)
Personal Hygiene/

Self-Care
Health Appointments/ Follow-up Appointments
Satisfactory Dental Health
Choices/Decisions Worked On
Dignity/Respect Issues

Experiences Security/ Continuity
Expresses Rights/States Rights that are Important
Goal Progress

MEDICAL UPDATE: List the individual's health providers, hospitalizations, recent and upcoming appointments, and medications.
Health Providers

Medical/Dental/Mental Health (name, specialty, phone)
Hospitalizations -(date, hospital, purpose)
Recent/Upcoming Appointments- medical, dental, mental health (date, health provider, purpose)
Recent Appointments	Upcoming/Follow-up Appointments
Medications (name, strength, form, dose, purpose)
Individual	Signature	Date
Client
Guardian
Staff
WSC