CLIENT INTAKE FORM
Client AIM: Yes No
PARTNER INFORMATION
File Number:
First Name: ______
Intake Date (m/d/y):
Middle Name: ______
Last Name: ______
D.O.B. (m/d/y) ______
Gender: ______
CLIENT INFORMATION
Client AIM: Yes No
First Name:
File Number:
Middle Name:
Gender: Male Female
Last Name: Sexual Orientation:
Address Home Work Date of Birth (m/d/y):
Street:
Apt. ______City:
Postal Code: With Which Ethno-
Racial Group Do You Identify (see list)
Year of Entry into Canada
Telephone:
Home/Ext Leave Message
Work/ Ext Leave Message
Cell: Leave Message
Language At Home:
(see list)
Fluency In English
Fluent Some Fluency Not Fluent
CASE INFORMATION
Government Level of Employment Status How Did You Hear About FST Education Status
Subsidization None Referred by: ______
Organization/Phone#: ______
Ont. Works Client Refused to Provide Social Services Not Specified
ODSP Self Employed Legal Services Elementary School
OAS/CPP Full Time Family/Friends/Neighbours Partial High School
GIS Part Time Educational High School Diploma
GAINS Occasional Health Some College or University
EI Unemployed Media College University Degree
Child/Spousal Support Homemaker Employer Some Post Graduate School
Long Term Disability Student Previous Contact Post Graduate Degree
Student Grant Loan Retired Skills Training
Disabled Client Refused to Provide
LTD/STD
(Individual) Income:
Gross Annual Family Income:
Fee Assessed: # of People Supported by Income:
Fee To Scale:
Relationship Status Barriers to Access
Married No
Separated Physical
Divorced Hearing (Deaf, Requires An Aid)
Widowed Vision (Partially sighted, blind)
Common-Law Speech (Mute, Speech Impediment)
With Partner Living Together Mobility (Uses A Walking Stick, Wheelchair)
With Partner Not Living Together
Single Other Specify:
CASE:
Issues/Problems
Primary: Secondary: Tertiary:
Client Intake Summary:
Child(ren):
Name: ______Age: ______Gender: ______
Name: ______Age: ______Gender: ______
Name: ______Age: ______Gender: ______
Name: ______Age: ______Gender: ______
Intake Worker Name: Restrictions: ______
______
Clustering Reason: Individual Program: Delivery:
Couple
Family
Non-related
Counsellor Gender:
Preferred Counsellors: Counsellors not to be assigned: Location:
(see list)
Assigned Counsellor:
Appointment Date:
(form revised: July 18, 2008) (Page 1 of 2)