ESM Client ID:                                                          

                               

ESM Release of Information:   Yes        No

                                                                     Intake Form

Provider ID:

                                                                   Family Residential

Enrollment Date:               /            /
                        mm          dd          yyyy

         & Sober Living
        Adult                                    
                                                                         ALL QUESTIONS MARKED WITH A  MUST BE COMPLETED.	
  	1. First  Name:	Middle Initial:	Last Name: 	Suffix:	
	2. Highest Grade Completed:	
		Not of school age		High school diploma/GED		College degree or higher		No formal education	
		Some schooling, no high school		Some college		Other credential (degree, certificate)		Unknown	
		Some high school		Associates degree					
	3. Gender:       Male  	Female  	Transgender  	4. Birth Date:	       /          /
mm    dd      yyyy	
	5. SSN:	If client refuses to give SSN or it is unknown, enter 999-99-9999 	
PERSONAL INFO>ADDRESS Section 
	6a. Address Type:	Home    Near Homeless    Homeless     	See Job Aid in the Intake Manual to determine Homeless vs. non-Homeless!  	
 If Address Type is “Homeless”, only enter the city/town and zip code where client is usually homeless. Do not use the Program’s city/town/zip.	
	 Street Address:	 	Unit:	
	 City/Town:	        	State:		Zip code:    	
	6b. Is this your Primary Address?  Yes   		
 ALTERNATE NAME Section
	If client has an alternate name, complete the following:				
	7a. First  Name:	Middle Initial:	Last Name: 		
            7b. Name Type:	 Alias    Nickname    Known by        Married Name     Maiden Name      Name at Birth        Prior Marriage Name 	
CLIENT CHARACTERISTICS>DEMOGRAPHICS Section
	8a. Are you Spanish/ Hispanic/Latino?	Yes      No                                                    	
 If ‘yes’ to Question 8a, complete Question 8b.                               If ‘no’ to Question 8a, go to Question 9	
	
8b. Which of the following ethnicities best describes you?

______ Central American                                    ______  Mexican, Mexican American, Chicano              ______  South American
______ Cuban                                                     ______  Puerto Rican                                                      ______  Unknown
______ Dominican                                               ______  Salvadoran                                                        ______  Other, specify _____________________    
                                                                                                                               	
  If ‘no’ to Question 8a, Select one from below	
	9.  What is your primary Ethnicity/Ancestry?  (select one only)                                                                                                                 	
		African		Chinese		Latin American Indian	
		African American		Eastern European		Middle Eastern	

Client Demographics				 Intake Form

		American		European		Portuguese	
		Asian Indian		Filipino		Russian	
		Brazilian		Haitian		Thai	
		Cambodian		Japanese		Vietnamese	
		Cape Verdean		Korean		Unknown	
		Caribbean Islander		Laotian  		Other, specify		

	10. What is your race?  (check all that apply)                                                                                                         	
		American Indian/Alaskan Indian		Native Hawaiian or Pacific Islander		Unknown	
		Asian		White		Refused	
		Black, African American		Other, specify:			
							
	11. In what language do you prefer to read or discuss health related materials?	
		American Sign Language		Haitian Creole		Russian	
		Cambodian (Khmer)		Hmong		Spanish	
		Cape Verdean Creole		Korean		Vietnamese	
		Chinese		Laotian 		Other, specify ______________________	
		English		Portuguese				
							
HOUSEHOLD CHARACTERISTICS Section
	12. Number of Adults in Household:
     (if client is Homeless, enter 1)	13. Number of Children Living in Household (children under 19):
     (children currently living with the client whether or not related)	
	14a. Client Income:   $	14b. Income Frequency:	 Weekly    Bi-Weekly    Monthly    Annually    	
	15. Source of Income:  (Check all that apply)			
	 	Wages/Salary		Veterans Disability Payment		Retirement - Social Security	
		Child Support		Private Disability Payment		Retirement/Pension - Private	
		Alimony		Public Assistance - TANF		Veterans Pension	
		Disability		Public Assistance - General		Non-employment Cash Income	
		Disability - SSI		Unemployment Compensation		None	
		Disability - SSIDI		Workers Compensation		Other	
							
	16. Received Income Verification:  	                                                 	
	17. Marital Status:        Never Married         Married        Divorced         Widowed        Separated       Significant Partnership Rlat.	
INSURANCE Section (Data Entry:  Go to Face Sheet and select Insurance on the left navigation bar.)
       	18. Insurance Type:				
	 Uninsured	 MC  (Medicaid / MassHealth /   MBHP	 MP   (Medicare –Over 65-some  disabled)                	  VA   Veterans   Administration  	
	 HM   Private HMO – through 
                employment or client  pay	 CI   Private Insurance – through  employment 
             or  client pay with  no subsidy	 OT   Other - Includes State subsidy –  
               ConnectCare /  Health Safety Net                       	
	Insurance Company Name 
Not required if uninsured:                                                                       	Policy Number:    
If Insurance Type is MC, the MassHealth Number, which begins with “100”,  must be entered. 	
	
Data Entry:
	If entering a New insurance record, enter the Enrollment Date as the Insurance Effective Date. 
If existing client with new insurance, end date previous insurance record with day before this Enrollment Date
If existing client and the insurance has Not Changed since the client’s last enrollment (whether or not at your program), simply hit SAVE!!!	
	19. Is this your Primary Insurance?	Yes     No  	
	If the client has additional insurance coverage, complete the following. If not, intake is complete.	
       	20. Additional Insurance Type:  Note:  Uninsured is not an option under additional insurance.		
	 MC  Medicaid / MassHealth /  MBHP	 MP   Medicare –Over 65-some  disabled               	  VA   Veterans  Administration	
	 HM –Private HMO –  through
               employment  or client   pay	 CI  Private Insurance – through   employment 
             or client pay with  no subsidy)	 OT  Other - Includes State subsidy –   
              ConnectCare / Health Safety Net)                         	
	Insurance Company Name:	Policy Number:    
If Insurance Type is MC, the MassHealth Number, which begins with “100”,  must be entered.	
 Note:  Relations are captured on Children’s Intakes