portrait

simplex

Salyer

July, 2005

2319

Intake Worksheet

Page of

Intake Worksheet

Intake Number:

Intake Name:

Priority:

Status Reason: Date Received: Time Received: Source:

Person Information:

Intake Name:

RECORDS CHECK

[ X ]

All Program Cases

(

Received By:

Worker Assigned:

Date Assigned:

County of Incident:

Household Information:

Name:

Address:

County:

Directions:

Phone:

Adult Information (Greater than 18 years of age) Child Information (18 years of age or less)

Name:

Address:

Directions:

Phone:

DOB/Age:

Unknown

Race:

Ethnicity:

Tribal Affiliation:

School:

Grade:

Reporter

Source:

Name:

Address:

Directions:

Phone:

DOB/Age:

Unknown

Race:

Ethnicity:

Tribal Affiliation:

Additional Details:

Program

Begin Dt

Relationship Summary

Referral Information

Current Allegation(s) Summary

Incident Date:

Finding Date:

Finding:

Victim:

Perpetrator:

Allegation:

Expungement Date:

Reason:

Perpetrator History

Intake #: Received Date:

Incident Date:

Finding Date:

Finding:

Victim:

Perpetrator:

Allegation:

Expungement Date:

Reason:

Department Decision

- Priority:

Organization Involved

Tools Used

Maltreatment Screening Tools

Priority Response Decision Tools

Allegation Type:

Incident Location:

Victim Living Status:

Victim Living Arrangement:

Self Neglect:

Yes

Allegation Type:

None