Intake Form
Family Residential
& Sober Living
Children	 ESM Release of Information:   Yes        No
     Parental Consent	
		Enrollment Date:               /            /
                                       mm       dd         yyyy	
		ESM Clint ID: 	Provider ID:	
 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     	If child comes from Foster Home (i.e., Institution) code as Homeless.	
If Address Type is “Homeless”, only enter the city/town and zip code where client/family was usually homeless.
Only use Program’s city/town/zip if a newborn or child that  has been in foster care since birth.	
	 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 	
CULTURAL 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)	
	If the child has income (e.g., social security survivor’s benefit), mark zero here but re-open the parent’s Face Sheet and 
Add a new HC record to add Family Income.  Add Income as of the date the child entered the program.	
	
0

14. Client Income: 	Not required when Income is $0: Source of Income, Frequency of Income, 	
	15. Marital Status:        Never Married       	
INSURANCE Section  (Data Entry: Go to Face Sheet and select Insurance form the laft 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.	

List Parent(s)/Caregiver(s) 
NOT Siblings – Each sibling will have their own Intake.

RELATIONS Section  
 	21. (Caregiver/Parent) First  Name:	22.(Caregiver/Parent) Last Name: 	

	23. Relation Type?  (check only one)                                                                                                         	
		Parent		Step-parent		Guardian	
		Caretaker relative		Foster parent		Other, Specify _______________________	
		Unrelated caregiver		Grandparent			

Fill out second box if both parents/caregivers are residing in your program.

 	24. (Caregiver/Parent)  First  Name:	25. (Caregiver/Parent) Last Name: 	

	26. Relation Type?  (check only one)                                                                                                         	
		Parent		Step-parent		Guardian	
		Caretaker relative		Foster parent		Other, Specify ________________________	
		Unrelated caregiver		Grandparent