Intake and the Intake Form

#workbook #FirstContacts #gedit3

Intake and the Intake Form

This describes the nuts and bolts of intake. Involvement and negotiation with the family is covered in the working with families section.

I ask my client or their representative to bring a copy of their durable power of attorney (DPOA) document to our first appointment. This document identifies them as a decision-making authority for the client. In addition, I ask that they provide the client’s diagnoses and current medication prescriptions.

During the balance of the meeting, we clarify the client’s issues (the reasons I’m being consulted), make an agreement on the services I will provide, and I collect the information necessary to provide those services. I gather the following to fill my intake form:

Demographic information

Date services are initiated; the date of revisions. With ongoing care management, I often complete a new intake form when significant changes or additions are made.

Name, date of birth, age, sex, marital status, address, phone number(s). Does the client live alone or with others? Medical insurance (Medicare, or other), and I restate that my services are not covered by insurance. Preferred hospital.

Presenting problem/identified needs

I note what problems and needs my client, or my client’s representative, identify.

Care plan

A brief summary of the plan I will assist my client with. This is helpful if specific actions will be taken soon.

Emergency contacts, DPOAs and involved parties

Emergency contacts includes the names, relationship to the client, phone numbers, and emails of individuals my client has given me permission to communicate with, regarding my client’s status and care. There is likely to be an overlap with the client’s DPOA(s) for medical and financial decision-making.

Involved parties may include home care agencies, private care givers, bill payers, financial advisors, housekeepers, and close friends who provide care or support. Involved parties may also include a visiting pastor, Eucharistic minister, Rabbi, or other faith, or wellness practitioner, such as a meditation coach or masseuse.

Medical information

I record diagnoses; medications that includes over-the-counter drugs, vitamins and supplements; and name and contact information of their primary physician. Medical history is taken, when relevant to current care. If I’m to provide care management, I need the names and contact information of all involved physicians. I record the names of additional medical services such as physical, occupational, or speech therapy.

I note assist devices (cane, walker, wheelchair, medical alert button), if my client wears glasses or hearing aides, or if they use a pill box to help them take medications.

If I will be managing my client’s care and attending their doctors appointments, I may need their pharmacy contact information.

Additional information

Information that does not fit in the above categories: the client’s faith, cultural background, sexual orientation; ongoing involvement in a service organization, or a relevant education or work history.


The referral source.


  • A through recording of the information necessary to provide your services.
  • Legal (DPOA)
  • Medical and related
  • Involved professionals
  • Involved family and friends

Published by Gary Bloom

Gary Bloom writes about learning, counseling, computers in education (and occasionally, some other stuff). He's a counselor, working in Edmonds.

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