(If Yes) how long ago was the last incident? Within the past 3 months 3-6 months ago 6-12 months ago    Domestic More than a year Client Know Client Refused Doesn’t  Violence Victim/Survivor (If Yes) are you currently fleeing? Yes No Client Does Not Know Client     Continue to Disability Assessment Client Name: Disability Assessment Does the client have a disabling condition? Yes No Client know Client Refused    doesn’t  Will the If Yes, Expected to be of long-continued Condition be and indefinite duration and substantially Disability Type (If Yes) Start Date long term? Disability Determination impairs ability to live independently? Yes Yes Yes Know Know Doesn’t Doesn’t Alcohol Abuse _____/_____/_____ No No No Refused Refused Yes No Notes: Client know doesn’t Client Refused Yes Know Yes Yes Doesn’t Know Doesn’t Drug Abuse _____/_____/_____ No Refused No No Refused Yes No Notes: Client know doesn’t Client Refused Alcohol and Yes Know Yes Yes Know Doesn’t Doesn’t Drug Abuse _____/_____/_____ No Refused No No Refused Notes: Yes No Client know doesn’t Client Refused Chronic Health Yes Know Yes Yes Know Doesn’t Doesn’t Condition _____/_____/_____ No Refused No No Refused Yes No Notes: Client know doesn’t Client Refused Yes Know Yes Yes Know Doesn’t Doesn’t HIV/AIDS No Refused No _____/_____/_____ No Refused Yes No Notes: Client know doesn’t Client Refused Mental Health Yes Know Yes Yes Know Doesn’t Doesn’t Problem _____/_____/_____ No No Refused No Refused Yes No Notes: Client know doesn’t Client Refused Developmental Yes Know Yes Yes Know Doesn’t Doesn’t Disability _____/_____/_____ No No Refused No Refused Yes No Notes: Client know doesn’t Client Refused
Domestic Violence Victim/Survivor (If Yes) how long ago was the last incident?  Within the past 3 months  3-6 months ago  6-12 months ago More than a year Client Doesn’t Know  Client Refused (If Yes) are you currently fleeing?  Yes  No  Client Does Not Know  Client Continue to Disability Assessment Client Name: Disability Assessment Does the client have a disabling condition?  Yes  No  Client doesn’t know  Client Refused Disability Type (If Yes) Start Date Will the Condition be long term? Disability Determination If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Alcohol Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Alcohol and Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Chronic Health Condition Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: HIV/AIDS Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Mental Health Problem Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Developmental Disability Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes:
SubCook_Initial_Intake_Assessment.docx