INDIVIDUAL AND FAMILY ASSESSMENT
Intake Checklist
Copyright © 2003-2005 Roger N. Meyer
All Rights Reserved
This list is a guide and focus tool for human service professionals conducting an initial or follow-up case intake visit in person with persons having cognitive disabilities and/or autism spectrum disorder (ASD).
Individual's name______________________________ Intake Date_________
Age/Status
____Child/adolescent
____Adult
____Public Assistance History: GA; AFDC (or current equivalent); Food Stamps; Section 8 or other housing assistance; post-incarceration
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School History
____Standard diploma/diploma track K-12
____Special education/section 504 K-12 student
____GED or other equivalency
____Community college
____Bachelor's level undergraduate degree completed
____Graduate/Professional Education (State degree if attained______________
____Vocational, apprenticeship, trade training ___________________________
____Other training and education______________________________________
Special Education History
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Living Independently? (Describe conditions to include housing, housing history, degree of habilitation care if care if supported)
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____Financial management issues, including debt, allowance, wages, salary, benefits, trust fund income, occasional or regular support by others
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____Medical insurance, dental, physical condition history, medications past and present, medication management, hospitalization history, current occasional or regular support by others, drug/alcohol history, sleep disorders, seizure history
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____Alcohol, Drug, Abusive Behavior History Includes arrests, TRO's, incarceration, criminal history including all charges, plea reductions, probation and/or parole history
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____Psychological/MH history include all diagnoses or "labels" provided by others, pharmaceuticals, hospitalization, clinic, therapy/counseling past and/or pres_____________________________________________________________________
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____Family of origin intact marriage, blended, siblings, raised by single parent, suggestion of same or related condition in primary family members, MH issues in biological or step parents/siblings
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____Friendship history, past intimate relationships _________________________________________________________________________
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____Current family relationships/setting_____________________________
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____Employment history/current employment status ________________________________________________________________
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____Adult agency history past/current DD, VR, public housing or supported housing, brokerage services, supported employment, day activities programs __________________________________________________________________
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____Competency issues capacity to sign agreement to represent __________________________________________________________________
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Adult Functional (for self-reporting of satisfaction, use scale of 1-10 from least able/dissatisfied to most able/satisfied)
____Transportation (driving, public transportation, mobility issues)
____Habilitation (care and maintenance of residence)
____Employability
____Leisure and recreation
____Special interests
____Hobbies
____Physical conditioning and exercise
____Personal care
____Shopping
____Communication with others (phone; Internet)
____Isolation v. social involvement (differentiate loneliness from satisfaction in being alone)
____Religious/church/spiritual involvement
____Control over scheduling, time management
____Making/keeping appointments
____Ability to locate and use needed resources
____Attention span/distractibility
____Self-identified special persons
____Self-description of mood, mood cycles
____Mood lability reported by others
____Self-reporting coherency (general)
____Self-reported history coherency
____Eye contact
____Speech (fluency, prosody, reciprocity, monologues)
____"Logic system"
____Problem-solving ability (be specific; start with self-reported challenges)
____Self-rated self-esteem
____Perseverations, fantasies, rumination
____Generalized awareness of others: intent, needs, boundaries
____Self-report about temper, anger, outbursts
____Sense of independence and control over life
____If diagnosed, extent of self-determination from denial to understanding (rank 1-5)
____Informal assessment of follow-up ability (rank from 1-5 none to high)
____Subjective assessment of truthfulness (rank from frank [1] to evasive [5]
____Records Elsewhere: Medical, psychological, educational, training programs, housing, VR and other employment readiness or vocational training, family records with relatives (who), protective services, juvenile or adult justice system, volunteer agencies, past employers, adoption or foster placement agencies, military, VA, arrest/conviction rap sheets, diversion programs, detox programs, public housing, religious/homeless service agencies, hospitals and clinics (transient or single-time use), civil suit records, employment agencies, state employment/unemployment insurance, medical or other insurance plan records, closed or expunged conviction records, legal or other records protected by professional privilege
____Self-Reported and Self-Ranked Priorities/Needs (No more than 5):
_______________Notes
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For additional notes, use a separate sheet
