INTAKE INTERVIEW	Date
Although this may be your first meeting with the individual, complete this form with as much information as possible. Prior to completing this form, complete the Checklist with the individual and guardian. The Intake form should be completed within one or two initial visits with the new client.
Name
Address	Phone
Primary Care Physician	Phone
Mental Health Professional	Phone
Dentist	Phone
Competent?	Yes	No	Provide guardianship papers, if necessary.	Social Security #
Guardian
Representative Payee
Who will be responsible for paying bills?
Bank
Account Types/Numbers
Intake Questions	YES	NO
Do you understand the services and supports in your Support Plan?
Do you have a copy of your Support Plan?
Do you have a copy of your Implementation Plan?
Did someone go over fire, safety, and emergency procedures with you?
Did you complete a supported living contract and request for services?
Did someone go over the Health and Safety and Housing Checklist with you?
Did you sign the authorization forms (medical, emergency , transportation)?
Did someone go over your due process rights and your rights and responsibilities in supported living with you?
Do you know who will be working with you and what their responsibilities are?
Did someone go over the grievance procedures and abuse reporting procedures with you?
List any medications (prescription and over-the-counter).

List upcoming appointments (what, location, date, time).

Describe what the individual would like to change, add, or do away with.

Describe what the individual would like the supported living program to help him/her accomplish.

Individual	Signature	Date
Client
Guardian
Staff/Title