INTAKE & ASSESSMENT CHECKLIST

Consumer: Date of Assessment: Assessor:

Update Today’s Date For Office Use Only

Assessor Check as completed Check Missing Documents
INTAKE PAPERWORK Intake Paperwork
Orientation Checklist
Orientation Checklist Complete Referral form
Consent to treatment
Complete Referral form Grievance Policy
Rights and Responsibilities
Consent to treatment Release of Information
Transportation form
Grievance Policy Consent to Photograph
Rights and Responsibilities Intake Survey
Assessment Forms
Release of Information Biopsychosocial
CAFAS
Transportation form Developmental Assessment
Treatment plan and Signature page
Consent to Photograph MICP
Assignments
Intake Survey Dr’s Appt
Dr’s Name
Nurse Appt
ASSESSMENT DOCUMENTS Case Staffing
Tx Plan delivered
Biopsychosocial Case Staffed
Collateral Documentation
CAFAS Medical Records
School Records
Developmental Assessment
Psych Evals
Treatment plan and Signature page List Other Documents :

Service Order
I understand that the above documents are missing & are
my responsibility to correct.
ASSIGNMENTS Assessor Signature:
Dr’s Appt Scheduled N/A Yes date No why?
Dr’s
Name
Nurse Appt Scheduled N/A Yes date No why?
Case Staffed N/A Yes date No why?
Tx Plan delivered N/A Yes date No why?

COLLATERAL DOCUMENTATION
Psych Evals req/rcv N/A Yes date No why?
Medical Records req/rcv N/A Yes date No why?
School Records req/rcv N/A Yes date No why?
List additional documents below

Accepted by: ___________________________________________________________________

Print name: ________________________________ Date: ___________________________
 INTAKE & ASSESSMENT CHECKLIST
Consumer: Date of Assessment: Assessor:

Accepted by: ___________________________________________________________________

Print name: ________________________________ Date: ___________________________