Case Management Intake Form

Case Management Intake Form Template for Canada

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Key Requirements PROMPT example:

"I need a Case Management Intake Form for our youth mental health program that complies with Ontario privacy laws, includes specific sections for suicide risk assessment, and accommodates both in-person and virtual service delivery."

Document background

The Case Management Intake Form serves as the primary documentation tool for initiating professional support services across Canadian social service and healthcare organizations. This document is essential when beginning a new client relationship, gathering comprehensive information needed for service planning while ensuring compliance with Canadian privacy legislation. It is designed to capture critical client data, including personal information, presenting issues, medical history, and consent for services, while maintaining appropriate privacy safeguards. The form supports various service contexts, from mental health to elder care, and helps establish the foundation for ongoing case management relationships. It includes both mandatory sections required for all clients and optional components that can be utilized based on specific service needs or circumstances.

Suggested Sections

1. Client Information: Basic personal information including name, date of birth, contact details, and identification numbers

2. Emergency Contact Information: Details of primary and secondary emergency contacts

3. Presenting Issues: Description of current challenges, concerns, and reasons for seeking services

4. Medical Information: Current health status, medications, allergies, and relevant medical history

5. Current Living Situation: Housing status, household composition, and living arrangements

6. Income and Employment: Employment status, income sources, and financial situation

7. Consent and Privacy: Client consent for services and information sharing, privacy policy acknowledgment

8. Risk Assessment: Initial screening for immediate risks or safety concerns

Optional Sections

1. Cultural Background: Information about cultural identity, language preferences, and religious/spiritual beliefs - used when providing culturally sensitive services

2. Legal Status: Information about legal issues, custody arrangements, or court orders - used when legal matters are relevant to case management

3. Education History: Educational background and current educational status - used when education-related goals are part of case management

4. Substance Use History: Information about current or past substance use - used when addiction services may be needed

5. Previous Service History: History of involvement with other service providers or agencies - used when coordination with other services is needed

6. Military Service: Details of military service and veteran status - used when working with veterans

Suggested Schedules

1. Consent Forms: Collection of required consent forms including information sharing, release of information, and service consent

2. Rights and Responsibilities: Document outlining client rights, responsibilities, and agency policies

3. Service Agreement: Details of services to be provided, expectations, and conditions

4. Resource List: List of community resources and referral information relevant to client needs

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Social Services

Mental Health

Addiction Services

Youth Services

Elder Care

Disability Services

Homeless Services

Family Services

Refugee Services

Relevant Teams

Intake

Case Management

Social Services

Clinical Services

Program Administration

Quality Assurance

Client Services

Operations

Community Outreach

Relevant Roles

Case Manager

Social Worker

Intake Coordinator

Program Director

Clinical Supervisor

Mental Health Worker

Addiction Counselor

Family Support Worker

Healthcare Navigator

Client Services Coordinator

Program Manager

Outreach Worker

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