Document Sample
INTAKE (DOC) Powered By Docstoc
					(To save you time, print this form out, complete your information, & bring to your first appointment)

Case Intake Form                                                                    Date: _____________________
Crossroads Pregnancy Resource Center
Data Entry: Client File (General Tab)

First Name:                                                      Last Name:                                             MI:

Address:                                                         City:                                       State:           Zip:

Home Phone:                                          Work Phone:                                    Cell Phone:
 Block caller ID                                     Block caller ID                               Block caller ID
Email:                                                                      Employer & Job Title:

Is it OK for us to contact you? (Check 1 or more options)
 No  Email  Mail  Phone
Birth Date:                                  Age:                        SSN:                  Occupation/School:

Case Intake (Client Questions)
Data Entry: Case Form (Client Questions)

How did you hear about us? (check one)
 800#/Hot Line  Agency          School     Internet ______________________________
 Church           Walk-in       Web Site                 (which site?)

 Friend/Relative  Yellow Pages  Other CPC  Other _________________________________
What outside help are you receiving? (check all that apply)
 Church       Friends  Insurance  WIC       Parents  Boyfriend/Fiance’  Baby’s Father
 Food Stamps  Husband  Medicaid  Other CPC  Other _________________________________
How do you hope we can help you today? _________________________________________________________________________________

How are you feeling emotionally (in your heart & mind)? ____________________________________________________________________
How are you feeling physically (in your body)? _____________________________________________________________________________
Have you smoked or used medication, drugs, or alcohol recently? Describe _____________________________________________
Do you have any mental health or medical concerns or issues? _______________________________________________________

How old were you when you became sexually active? _________
Have you been tested for a sexually transmitted disease?  Yes  No
Do you have any STDs?  AIDS  Chlamydia  Crabs  Genital Warts                  Gonorrhea  Herpes  HIV  HPV  Syphilis  Other
Are you a victim of abuse? (Remember, we must report minors who are abused)               Mental/Verbal  Physical  Rape  Sexual
What is your current relationship with God?          Close  Desire to be Better  None  Okay
Religion ______________________________________                 11. Church ____________________________________________
Income Level                   Marital Status                                     Education (highest level completed)
 Dependent (Child)             Single Never Married  Engaged                 Dropped Out in ____ Grade GED Certificate
                                                                                  High School Diploma      Trade School
 Unemployed                    Divorced  Separated
                                                          Married
 Welfare/SSI                   Widowed Living Together                         College Degree            Graduate Degree
 Child Suport                 Student Status
 $0-$14,999                    Middle School or Jr. High    High School
 $15,000-$29,000               College or University        GED / Adult Ed
 $30,000+                      Trade School/Other           Not Student
                                                                                                                              Case Intake, p. 2
Pregnancy Information
Number of Prior Births          Number of Abortions          Number of Miscarriages      Number of Children

First date of last period: ____________ Did you take a pregnancy test?________ What type:______________ Results:               +    or   -
If you are pregnant, which statements apply to you?
I will parent                    I want to know more about parenting    I know that I will have this baby but not sure what to do after
I will abort                     I want to know more about abortion     I have no idea but am considering these options __________________
I will make an adoption plan     I want to know more about adoption

What are your feelings on abortion?______________________________________________________________________________
Would you consider finding a loving family that could provide everything this baby needs for a healthy, happy life? _______________
Would you like to speak with another mom who chose adoption? _______________________________________________________
What community resources are you aware of that could make parenting easier for you? _____________________________________
Who knows about your situation, and what has their input been like? ____________________________________________________

Visit Information     (Data Entry: New Case Visit Form)

Have you been here before? _______ If so, when?________________ Under what name? ________________________________

What is the primary reason for this visit?
 Pregnancy Test        Baby/Maternity Supplies  General Counseling/Support  Group Class
 Ultrasound           Post-Abortion Healing STD / Abstinence Education  Referrals to Community Resources
 Abortion Information  Adoption Information  Parenting Information/Support  Other _________________________________
Crossroads is a crisis intervention agency providing self-administered pregnancy tests, peer consultations, and practical
help at no cost. Client Advocates are bound by our Commitment of Care (posted in the lobby). Client Advocates are trained
to help with crisis pregnancies; however, not all are degreed or licensed counselors. Thus, support provided is not
intended as a substitute for professional therapy.
Crossroads offers information, emotional and spiritual support, and practical help to clients who genuinely seek our caring
services. Any attempt to obtain our services or resources under false pretense is prohibited. To protect your privacy and
the privacy of our Client Advocates, use of electronic recording devices are not allowed at Crossroads.
Counseling is an interactive process that can be emotional, and Crossroads provides a safe place for you to sort through
these emotions. This requires teamwork and open and honest communication between you and your Client Advocate.
Thus, if you feel you might have a better connection with another Advocate, please let one of us know.

If your self-administered pregnancy test appears positive or you receive an ultrasound to confirm pregnancy, you should
go to a medical doctor as soon as possible for a physical exam, as we do not provide prenatal care.

Client Advocates are required to keep your information CONFIDENTIAL (private) except in the following 3 cases:
1. Select information may be shared with a supervisor only to ensure that your needs are being properly met.
2. Due to concern for your safety and/or Louisiana State Law, Crossroads must report knowledge or suspicion of a client
    who is suicidal, homicidal, abusing a minor (age 17 or younger), or a minor being abused.
3. If Crossroads has knowledge of a crime (i.e. Carnal Knowledge of a Juvenile – a minor having sex with an adult), LA
    State Law requires us to report such instances to a law enforcement agency for further investigation.

I have read and understand the statements above. I request services related to pregnancy provided by Crossroads
Pregnancy Resource Center at no charge. Because I intentionally seek these services for my own benefit, I release
Crossroads and its paid and volunteer staff from any and all liability arising out of or connected with this pregnancy,
particularly with regard to any errors in diagnosis based on the pregnancy test or ultrasound.

Client’s Signature _____________________________________________ Date_________________________

Consultant’s Signature_________________________________________________ Date__________________