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| Case Intake & Assessment (STEP) | | |
| Date of Initial Contact (DATE) | | |
| Summary of Initial Client Presentation (TEXT) | | |
| Reason for Case Intake (SELECTION options: Referral, Self-Referral, Legal Mandate, Other) | | |
| Client Age (NUMBER) | | |
| Primary Concerns Reported (SELECTION options: Housing, Financial, Legal, Mental Health, Physical Health, Employment, Family/Relationships) | | |
| Referring Agency (if applicable) (TEXT) | | |
| Initial Observations & Potential Risks (TEXT) | | |
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| Client Information Verification (STEP) | | |
| Full Name (TEXT) | | |
| Date of Birth (YYYY) (NUMBER) | | |
| Address (TEXT) | | |
| Phone Number (TEXT) | | |
| Identification Type (SELECTION options: Driver's License, Passport, Social Security Card, Other) | | |
| Copy of Identification (UPLOAD) | | |
| Emergency Contact Name (TEXT) | | |
| Emergency Contact Phone (TEXT) | | |
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| Needs Assessment & Goal Setting (STEP) | | |
| Client's Perceived Needs (in their own words) (TEXT) | | |
| Primary Areas of Need (select all that apply) (SELECTION options: Housing, Employment, Healthcare, Financial Assistance, Legal Aid, Education/Training, Mental Health Support, Substance Abuse Support, Transportation) | | |
| Client's Income (monthly) (NUMBER) | | |
| Client's Strengths and Resources (TEXT) | | |
| Client's Level of Engagement (SELECTION options: Highly Engaged, Moderately Engaged, Low Engagement, Unsure) | | |
| Initial Case Goals (collaboratively established) (TEXT) | | |
| Goal Review Date (DATE) | | |
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| Resource Identification & Allocation (STEP) | | |
| Primary Support Worker Assigned (SELECTION options: Worker A, Worker B, Worker C, Pending Assignment) | | |
| Specialized Services Required (SELECTION options: Legal Aid, Mental Health Support, Financial Counseling, Medical Care, Housing Assistance, None) | | |
| Estimated Budget Allocation (NUMBER) | | |
| Supporting Documentation (e.g., referrals) (UPLOAD) | | |
| Referral Date (DATE) | | |
| Transportation Resources (SELECTION options: Agency Provided, Client Responsibility, Pending, Not Required) | | |
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| Service Delivery & Implementation (STEP) | | |
| Service Delivery Start Date (DATE) | | |
| Description of Services Provided (TEXT) | | |
| Number of Sessions Completed (NUMBER) | | |
| Service Delivery Method (SELECTION options: In-Person, Remote (Video), Remote (Phone)) | | |
| Supporting Documentation (e.g., Progress Notes) (UPLOAD) | | |
| Duration of each session (DATE) | | |
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| Progress Monitoring & Evaluation (STEP) | | |
| Date of Progress Review (DATE) | | |
| Progress Score (1-5) (NUMBER) | | |
| Summary of Progress Made (TEXT) | | |
| Challenges Encountered & Solutions Implemented (TEXT) | | |
| Overall Assessment of Progress (SELECTION options: On Track, Slightly Behind Schedule, Significantly Behind Schedule, Requires Adjustment) | | |
| Areas Requiring Further Attention (SELECTION options: Financial Support, Housing Assistance, Emotional Support, Legal Aid, Healthcare Access) | | |
| Notes from Stakeholder/Client Feedback (if applicable) (TEXT) | | |
| Date of Next Review (DATE) | | |
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| Documentation & Record Keeping (STEP) | | |
| Date of Record Creation (DATE) | | |
| Summary of Initial Assessment Notes (TEXT) | | |
| Supporting Documentation (e.g., reports, correspondence) (UPLOAD) | | |
| Record Type (SELECTION options: Intake Record, Progress Note, Correspondence, Closure Record) | | |
| Detailed Actions Taken & Outcomes (TEXT) | | |
| Number of Pages in Attached Documents (NUMBER) | | |
| Case Manager Signature (SIGNATURE) | | |
| Record Identifier/Case Number (TEXT) | | |
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| Communication & Collaboration (STEP) | | |
| Last Client Contact Date (DATE) | | |
| Contact Method (Phone, Email, In-Person) (TEXT) | | |
| Summary of Communication & Key Discussion Points (TEXT) | | |
| Stakeholders Involved in Communication (SELECTION options: Client, Family Member, Legal Representative, Service Provider, Case Manager Supervisor) | | |
| Topics Discussed (SELECTION options: Progress Updates, Service Plan Review, Financial Matters, Concerns/Challenges, Goals/Objectives) | | |
| Next Communication Planned (Type) (TEXT) | | |
| Date of Next Communication (DATE) | | |
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| Risk Management & Safety (STEP) | | |
| Client’s Current Risk Level (SELECTION options: Low, Moderate, High, Critical) | | |
| Description of Identified Risks (TEXT) | | |
| Potential Risk Factors (Select all that apply) (SELECTION options: Substance Abuse, Mental Health Concerns, Domestic Violence, Financial Instability, Social Isolation, Neglect/Abuse, Other) | | |
| Safety Plan Details (TEXT) | | |
| Next Safety Plan Review Date (DATE) | | |
| Location of Potential Safety Concerns (LOCATION) | | |
| Staff Signature (Acknowledging Risk Assessment) (SIGNATURE) | | |
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| Case Closure & Transition (STEP) | | |
| Case Closure Date (DATE) | | |
| Summary of Case Outcomes & Progress (TEXT) | | |
| Client Satisfaction (Post-Closure) (SELECTION options: Very Satisfied, Satisfied, Neutral, Dissatisfied, Very Dissatisfied) | | |
| Recommendations for Future Support (if applicable) (TEXT) | | |
| Referral to Other Services (if applicable) (SELECTION options: Yes, No) | | |
| Details of Referral (if applicable) (TEXT) | | |
| Case Manager Signature (SIGNATURE) | | |
| Case Manager Name (Printed) (TEXT) | | |