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Main Facility: 3456 W Franklin Blvd, Chicago, IL 60624

Admin: 542 S Dearborn St, Ste 300, Chicago, IL 60605

773-533-6013

Pre-Intake Application

Intake Worker's Name

Referring Social Worker's Name

Referring Social Worker's Phone Number

Client Information

Client's Name

Client's Date of Birth

Format: 01/01/1990

Client's Last four #'s of SSN

Client's Phone Number

Client's Gender

Client's Preferred Language

Please select your preferred language below

Is the client a citizen of the United States?

Yes

No

Income & Shelter

Is this the client's first time homeless?

Yes

No

How long where you homeless?

Do you have Income?

Yes

No

Source of Income

Medical Information

Name of Hospital

Client's Date of hospital admission

Format: 01/01/1990

Through (Estimated date of discharge)

Format: 01/01/1990

Does the Client have a psychiatric history?

Yes

No

What is the client's psychiatric diagnosis?

Axis I

Axis II

Client's Date of Diagnosis

Format: 01/01/1990

Does the client present any of the following?

Cognitive Impairment? (e.g. memory, judgement, etc.)

Yes

No

Thought Disorder?

Yes

No

Dementia?

Yes

No

Paranoia?

Yes

No

Confusion?

Yes

No

If the client has an Acute/Principle illness or injuries, please list them below (one per line.)

Please check any if the following conditions apply to the client.

HIV

Diabetes

Hypertension

Seizure Disorder

Drug or Alcohol Abuse

Is the client taking Methadone?

Yes

No

Why is the client taking Methadone?

What is the client's Methadone dosage?

Insurance Information

What is the Client's Type of insurance? (Please check all that apply)

None

Medicaid

Aetna

Humana

Illinicare

CountyCare

Meridian

Molina Health

Medicare A/B

Veterans Administration

HMO/Private

Other Insurance:

Assistance Information

Is the client able to manage the following basic living skills without assistance?

Showering/Hygiene

Yes

No

Dressing Themselves

Yes

No

Manage Bowels/Bladder

Yes

No

Take Medicine As Prescribed

Yes

No

Change Medical Dressings

Yes

No

Manage Medical Supplies

Yes

No

If no to any of the above, How will the client need assistance?

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