Screening Intake Template

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					 Screening/Intake Assessment                    Comprehensive Basic Assessment                      Comprehensive Psychosocial
                                                      Applicable Service Sections
 Child and Family Development           Adult Day Services (PA-ADS)                             Day Treatment Services (PA-
  and Support Services, Parent           Adult Guardianship (PA-AG)                               DTX)
  Education Groups only (PA-             Adult Protective Services (PA-APS)                      Juvenile Justice Corrections
  CFD)                                   Case Management Services (PA-CM)                         Services (PA-JJC)
 Counseling, Support, and               Child and Family Development and Support                Opioid Treatment (PA-OTP)
  Education Services (PA-CSE)             Services (PA-CFD)                                       Outpatient Mental Health Services
 Crisis Response and                    Child Protective Services (PA-CPS)                       (PA-MH)
  Information Services (PA-CRI)          Domestic Violence (PA-DV)                               Psychiatric Rehabilitation
 Outreach Services (PA-OS)              Employee Assistance Program Services (PA-EAP)            Services (PA-PSR)
 Social Development and                 Family Preservation and Stabilization Services (PA-     Residential Treatment Services
  Enrichment Services for                 FPS)                                                     (PA-RTX)
  Children and Youth (PA-SDE)            Foster Care Services (PA-FC)                            Services for Substance Use
 Workforce Development and              Group Living Services (PA-GLS)                           Conditions (PA-SA)
  Support Services; and Financial        Guardianship Services for Minors (PA-GSM)               Wilderness and Adventure-Based
  Asset Building Services (PA-           Home Care and Support Services (PA-HCS)                  Therapeutic Outdoor Services
  WDS)                                   Immigrant and Refugee Resettlement (PA-IRR)              (PA-WT)
                                         Juvenile Justice Case Management Services (PA-
                                         Juvenile Justice Day Services (PA-JJD)
                                         Kinship Care Services (PA-KC)
                                         Pregnancy Support Services (PA-PS)
                                         Respite Care (PA-RC)
                                         Shelter Services (PA-SH)
                                         Supported Community Living Services (PA-SCL)
                                         Vocational Rehabilitation Services (PA-VOC)
                                         Volunteer Mentoring Services (PA-VM)
                                         Youth Independent Living (PA-YIL)

                                                       Assessment Elements
Intake or screening assessments      Comprehensive basic assessments include:                    Comprehensive psychosocial
include:                              a. information gathered for a screening/intake             assessments include:
a. identifying information,              assessment;                                              a. information gathered for the
     including name, date of birth    b. a preliminary evaluation of the request or need for          screening/intake assessment and
     and social insurance number         service;                                                     basic assessment;
     (if available);                  c. the person’s and/or family’s strengths and               b. psychiatric issues;
b. current residence;                    resources;                                               c. a mental status exam;
c. emergency health needs;            d. family relationships and formal and informal             d. alcohol and other drug use
d. emergency contacts (if any);          support systems;                                             assessment; and
e. safety, imminent danger or         e. the person’s past or current use of services from        e. assessment of non-substance
     risk of future harm, as             this organization or other organizations;                    addictive behaviors.
     applicable; and                  f. independent living skills, activities of daily living
f. legal status.                         assessment, as applicable;
                                      g. a screening for family violence, abuse, or neglect,
                                         or exploitation;
                                      h. mental health status and developmental screening,
                                         as applicable;
                                      i. trauma screening;
                                      j. alcohol and other drug use screening;
                                      k. educational and vocational information;
                                      l. financial status, including financial assistance and
                                         insurance coverage;
                                      m. housing status, history, and a description of living
                                         conditions; and
                                      n. other information necessary to provide services.
Note: The elements of the matrix can be tailored according to the needs of specific individuals or service design.

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