Intake Form Assignment

This week, you will be completing an intake form for a client. In the Unit 3 Reading, you were introduced to the concept of an intake form on page 82 (Box 3.1). Completing an intake form is a very common practice for human services professionals, and, as you can imagine, is a task that takes effective listening skills. In this activity, you are going to have the opportunity to complete an intake form for a client.

Please note that though you will be completing this Assignment in the course space, you have unlimited time to complete this task, so you should not feel any more pressure than if you were to complete the form and submit it to the Dropbox. You can re-enter the Assignment and change your answers later if you need to as well.

The sample intake form in your text is different from what you will be completing in this task. Each agency or office has slightly different intake forms, but the general idea is the same. To familiarize yourself with the intake form you will be completing, click here to see a sample intake form. This form explains what information is required in each field. You can see from the very beginning that you will need to use your listening skills as well as observe nonverbal cues and pay attention to the client very closely.

Next, you can take a look at a completed intake form. In Discussion this week, you met Luz. To review her story, click here. Then take a look at Luz�s completed intake form to see how her information is compiled. Feel free to use the sample intake form with the instructions for the fields as well as Luz�s intake form to help you as you complete your intake form activity. You may also want to have this blank intake form handy.

Intake Form Client

You have your choice of one of four clients to use for this Assignment. Go to the California Homeless Youth Project website, and watch the following four interviews:

The Street Through My Eyes
My Son Saved My Life
From Pillar to Post
Homeless Youth Finds Success With Transitional Housing
Source: California Homeless Youth: Video Wall. Retrieved from

Please keep in mind that some of the language used in the interviews is graphic, reflecting the harshness of the clients lives.

After you have watched all four videos, select one of the videos as your client for the intake form. Remember, the completed example intake form, Luz�s intake form, and the information in Chapter 3 page 81�83 will be your guide to successfully completing an assessment based on the client you select. You can watch the video as many times as you need to while you complete the form as well, so take your time. You may even want to note your client�s information before you get started so that you will feel more prepared.

Questions needed to be answered:

1. Which client did you choose?
2. Present the problem:
3. How did the client present in the Interview?
4. What were the client�s expressed Goals, Expectations and Requested Services?
5. Provide any additional Relevant Information.
6. What is your impression and recommendation for this client?


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