Client
Name:
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SSN:
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Intake Date:
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Referred
By:
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Phone:
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Ext:
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Email:
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Organization:
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Fax:
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1. ADULT (Not MR/DD)
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Date of Birth:
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Protective Services:
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Yes No |
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Gender:
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Male
Female |
Veteran:
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Yes No |
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Race:
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Black
White
Hispanic Other |
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Marital Status:
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Single
Married
Divorced Widowed |
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2. CUYAHOGA COUNTY RESIDENCY
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Address:
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City:
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State:
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Zip:
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Home Phone:
(with area code)
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Previous
Address:
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City:
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State:
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Zip:
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Length at Current Address:
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Owns
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Rents
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Titled Owner:
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Title Date:
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Market Value:
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All property ownership information can be obtained from Map Room at Homeowners Hotline (216) 443-7091.
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3. EVIDENCE OF SUBSTANTIAL MENTAL IMPAIRMENT
(A Completed Statement of Expert Evaluation Must Accompany Intake)
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Primary
Impairment
Diagnosis: |
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Mental
Illness:
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Yes No
Specify:
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Previous
Guardian:
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Yes No Name:
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Case Manager: Phone:
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Agency: Case Number:
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4.INDIGENCY
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Medicaid: |
Yes No
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Medicaid No:
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Medicaid Case No.:
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Medicare: |
Yes No
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Medicare No.: |
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Private Pay:
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Yes No
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Active Payeeship?:
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Yes No
Payeeship Name and Phone
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Income
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Amount
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Source
|
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Source
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Source
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Total
|
|
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Assets
|
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Value
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Private Prop.
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Real Estate
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Annual Rents
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Total
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5. SIGNIFICANT NEXT OF KIN WHO RESIDE IN OHIO
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Relative:
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Address:
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City:
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State:
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Zip:
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Phone:
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Relationship:
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Relative:
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Address:
|
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City:
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State:
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Zip:
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Phone:
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Relationship:
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6. COMPELLING DECISION (which requires legal authority to act)
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If there is a deficit, how does this interfere with the person's ability to provide an informed consent to care, treatment, placement or management of financial affairs? Please be specific:
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