Case Management Checklist Template

CASE MANAGEMENT CHECKLIST TEMPLATE Created by ChecklistGuro (https://checklistguro.com) --- CASE INTAKE & ASSESSMENT --- [ ] Date of Initial Contact [ ] Summary of Initial Client Presentation [ ] Reason for Case Intake (Referral, Self-Referral, Legal Mandate, Other) [ ] Client Age [ ] Primary Concerns Reported (Housing, Financial, Legal, Mental Health, Physical Health, Employment, Family/Relationships) [ ] Referring Agency (if applicable) [ ] Initial Observations & Potential Risks --- CLIENT INFORMATION VERIFICATION --- [ ] Full Name [ ] Date of Birth (YYYY) [ ] Address [ ] Phone Number [ ] Identification Type (Driver's License, Passport, Social Security Card, Other) [ ] Copy of Identification [ ] Emergency Contact Name [ ] Emergency Contact Phone --- NEEDS ASSESSMENT & GOAL SETTING --- [ ] Client's Perceived Needs (in their own words) [ ] Primary Areas of Need (select all that apply) (Housing, Employment, Healthcare, Financial Assistance, Legal Aid, Education/Training, Mental Health Support, Substance Abuse Support, Transportation) [ ] Client's Income (monthly) [ ] Client's Strengths and Resources [ ] Client's Level of Engagement (Highly Engaged, Moderately Engaged, Low Engagement, Unsure) [ ] Initial Case Goals (collaboratively established) [ ] Goal Review Date --- RESOURCE IDENTIFICATION & ALLOCATION --- [ ] Primary Support Worker Assigned (Worker A, Worker B, Worker C, Pending Assignment) [ ] Specialized Services Required (Legal Aid, Mental Health Support, Financial Counseling, Medical Care, Housing Assistance, None) [ ] Estimated Budget Allocation [ ] Supporting Documentation (e.g., referrals) [ ] Referral Date [ ] Transportation Resources (Agency Provided, Client Responsibility, Pending, Not Required) --- SERVICE DELIVERY & IMPLEMENTATION --- [ ] Service Delivery Start Date [ ] Description of Services Provided [ ] Number of Sessions Completed [ ] Service Delivery Method (In-Person, Remote (Video), Remote (Phone)) [ ] Supporting Documentation (e.g., Progress Notes) [ ] Duration of each session --- PROGRESS MONITORING & EVALUATION --- [ ] Date of Progress Review [ ] Progress Score (1-5) [ ] Summary of Progress Made [ ] Challenges Encountered & Solutions Implemented [ ] Overall Assessment of Progress (On Track, Slightly Behind Schedule, Significantly Behind Schedule, Requires Adjustment) [ ] Areas Requiring Further Attention (Financial Support, Housing Assistance, Emotional Support, Legal Aid, Healthcare Access) [ ] Notes from Stakeholder/Client Feedback (if applicable) [ ] Date of Next Review --- DOCUMENTATION & RECORD KEEPING --- [ ] Date of Record Creation [ ] Summary of Initial Assessment Notes [ ] Supporting Documentation (e.g., reports, correspondence) [ ] Record Type (Intake Record, Progress Note, Correspondence, Closure Record) [ ] Detailed Actions Taken & Outcomes [ ] Number of Pages in Attached Documents [ ] Case Manager Signature [ ] Record Identifier/Case Number --- COMMUNICATION & COLLABORATION --- [ ] Last Client Contact Date [ ] Contact Method (Phone, Email, In-Person) [ ] Summary of Communication & Key Discussion Points [ ] Stakeholders Involved in Communication (Client, Family Member, Legal Representative, Service Provider, Case Manager Supervisor) [ ] Topics Discussed (Progress Updates, Service Plan Review, Financial Matters, Concerns/Challenges, Goals/Objectives) [ ] Next Communication Planned (Type) [ ] Date of Next Communication --- RISK MANAGEMENT & SAFETY --- [ ] Client’s Current Risk Level (Low, Moderate, High, Critical) [ ] Description of Identified Risks [ ] Potential Risk Factors (Select all that apply) (Substance Abuse, Mental Health Concerns, Domestic Violence, Financial Instability, Social Isolation, Neglect/Abuse, Other) [ ] Safety Plan Details [ ] Next Safety Plan Review Date [ ] Location of Potential Safety Concerns [ ] Staff Signature (Acknowledging Risk Assessment) --- CASE CLOSURE & TRANSITION --- [ ] Case Closure Date [ ] Summary of Case Outcomes & Progress [ ] Client Satisfaction (Post-Closure) (Very Satisfied, Satisfied, Neutral, Dissatisfied, Very Dissatisfied) [ ] Recommendations for Future Support (if applicable) [ ] Referral to Other Services (if applicable) (Yes, No) [ ] Details of Referral (if applicable) [ ] Case Manager Signature [ ] Case Manager Name (Printed) --- END OF TEMPLATE --- Transform this text into a digital, automated, and trackable mobile app! Visit: https://checklistguro.com/templates/case-management/case-management-checklist-template (Click "Install Template" to launch your digital inspection tool immediately)