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Youth Intake Packet
Step
1
of
15
6%
SECTION 1: Intake Cover Sheet
Youth Name:
Date of Intake
MM slash DD slash YYYY
Time of Arrival
Hours
:
Minutes
AM
PM
AM/PM
Staff Member Completing Intake*
Referral Source (Agency or Individual)
Case Number *
Placement Type
Emergency Placement (<72 hours)
Short-Term Residential (Up to 90 days)
Long-Term Residential (90+ days)
Other:
Untitled
Immediate Needs Identified Upon Intake (Check all that apply)
Medical attention (Non-Emergency)
Emergency Medical/Hospitalization
Mental Health
Crisis/Stabilization
Clothing Hygiene supplies
Safety Concerns/Immediate danger
Food/Drink
Shelter (Immediate need)
Rest/Sleep
Other
Untitled
Notes on Immediate Needs (Specify 'Other' or details on safety concerns)
Date of Birth
MM slash DD slash YYYY
Age Of Intake
Sex Assigned at Birth
Female
Male
Intersex
Unknown/Not Provided
Current Gender Identity (If different from Sex Assigned at Birth)
Race/Ethnicity (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a Native
Hawaiian or Other Pacific Islander
White
Two or More Races
Other
Decline to State/Unknown
Religion/Spiritual Practice (If any)
Birthplace (City, State/Country)
Primary Language Spoken
Documents Provided at Intake (Check all received)
Original Birth Certificate
Social Security Card/Number
State ID/Driver's License
Passport/Visa Documentation
School Records
Medical Insurance Card/Information
Immunization Records
DCF/Court Documents (Case Plan, Shelter Petition, etc.)
None Provided
Other (Specify)
Other (Specify)
Accessibility, Dietary, or Cultural Needs (Please detail accommodations required)
SECTION 3: Custody & Legal Status
Current Custody Status *
DCF/Child Protective Services Custody
DJJ (Department of Juvenile Justice) Commitment
Parental/Non-DCF Legal Guardian Custody
Tribal Custody
Emancipated Minor
Other (Specify below)
Unknown/Unverified
Untitled
Legal Guardian Information (Current Contact)
Case Manager / Placement Worker Information
Legal Documents Received (Check all present in file)
Current Court Orders/Placement Authorization
Shelter Petition
Current Case Plan
No-Contact Orders (Restraining Orders)
Paternity Affidavit
Judicial Review Reports
Documents Pending/Missing
None Received
Missing Documents & Follow-Up Plan
Trafficker/Exploiter Identified?
Yes
No
Unknown/Not Disclosed
If Yes, provide known details about the identified Trafficker/Exploiter (Name, known aliases, relationship, nature of exploitation)
SECTION 4: Family & Significant Contacts
Parent/Guardian #1 Details
Name (parent # 1)
Relationship (parent # 1)
Contact Info (parent # 1)
Parent/Guardian #1 Contact Allowed? Yes, Unrestricted Yes, Supervised Only No, Contact Prohibited (Explain reason/order) Unknown
Yes, Unrestricted
Yes, Supervised Only
No, Contact Prohibited (Explain reason/order)
Unknown
If no, Contact Prohibited Explain reason/order 1
Parent/Guardian #2 Details
Name
Relationship
Contact Info
Parent/Guardian #2 Contact Allowed?
Yes, Unrestricted
Yes, Supervised Only
No, Contact Prohibited (Explain reason/order)
Unknown
If no, Contact Prohibited Explain reason/order
Siblings/Other Children in Family Unit (Please list Name, Age, and Contact Status for each)
Other Significant Persons (Mentors, former caregivers, spiritual leaders, etc. List Name, Relationship, and Contact Info)
Visitation Schedule and Restrictions (Detail any formal or informal limitations on visitation, including location, time, and supervision requirements)
SECTION 5: Social History
Family Background Summary (High-level overview of family environment, stability, known history of abuse/neglect, or separation. Maintain trauma-informed language.)
Known Trauma History (Summarize known types of trauma experienced, *without* graphic detail. Focus on themes: displacement, abuse, neglect, exploitation, witness to violence, loss.)
Known Triggers (Identify known stimuli that may cause distress or dysregulation for the youth)
Current Coping Strategies (List youth's typical healthy and unhealthy responses to stress/trauma)
Human Trafficking Indicators (Check all relevant indicators observed or reported)
Has run away or been reported as AWOL previously
Lacks appropriate documentation (ID, SSN)
Has unexplained injuries or medical issues
Displays fear, anxiety, or hypervigilance
Inconsistent/implausible stories about background
Has multiple cell phones or communication devices
Has expensive items/brands beyond means
Refers to an 'owner' or 'boyfriend'
Has commercial branding (tattoos, clothing)
History of being moved frequently or displacement
Unknown/Not Applicable
Strengths, Interests, and Positive Cultural Considerations (List positive characteristics, hobbies, talents, and cultural aspects important to the youth)
SECTION 6: Referral Documentation Checklist
Received Documents Checklist (Mark 'Yes' if the document is present in the file)
Legal: Court Orders, Shelter Petition, Case Plan
Received
Missing/Pending
Not Applicable
Assessments: Psych/Social Assessment, DCF Safety Plan
Received
Missing/Pending
Not Applicable
Medical: Physical Exam, Immunization Record, Insurance Card
Received
Missing/Pending
Not Applicable
Education: School Withdrawal Form, Current IEP/504 Plan
Received
Missing/Pending
Not Applicable
Placement History: Detailed History of Placements
Received
Missing/Pending
Not Applicable
Referring Agency/Worker Contact Information (Name, Agency, Phone, Email)
Missing Documents & Follow-Up Needed (Describe any critical documents missing and the plan/person responsible for obtaining them)
Urgent Follow-Up Required Checklist (Check all that apply immediately after intake)
Schedule Initial Medical Appointment
Schedule Initial Dental Appointment
Emergency Authorization for Medication
Notify School District/Enrollment
Contact Legal Counsel
Safety Plan Review/Implementation
Staffing/Case Review Meeting
Other Urgent Follow-Up
SECTION 7: Medical History & Health Information
Date of Last Physical Exam
MM slash DD slash YYYY
Date of Last Dental Exam
MM slash DD slash YYYY
Date of Last Vision Exam
MM slash DD slash YYYY
Date of Last Dental Exam
MM slash DD slash YYYY
Health Insurance Carrier and Policy Number (Required)
Chronic Medical Conditions (List all known, e.g., Asthma, Diabetes, Epilepsy)
Allergies (Medication, Food, Environmental - Specify reaction and severity)
Current Medications (Please list Name, Dose, Frequency, and Prescribing Provider for *each* medication. Use separate lines.)
Immediate Medical Needs and Follow-Up (Check all current or urgent medical issues)
Recent/Current Illness
Unexplained Injuries Requiring Evaluation
Sexual Health Screening Required
Pregnancy Test Needed/Confirmed
Substance Withdrawal Monitoring
New Prescription Required
None Identified
Describe Immediate Medical Needs and Follow-Up Plan
SECTION 8: Mental Health & Behavioral Information
Current Mental Health Diagnoses (List all official diagnoses and date/source)
Current Mental Health Providers (List Therapist/Psychiatrist Name, Agency, and Contact Info)
Current Risk Levels Assessment (Based on observation and report)
Self-harm/Suicidal Ideation
Low
Medium
High
Unknown
AWOL/Runaway Risk
Low
Medium
High
Unknown
Verbal Aggression Risk
Low
Medium
High
Unknown
Physical Aggression Risk
Low
Medium
High
Unknown
Vulnerability to Re-Exploitation
Low
Medium
High
Unknown
History of Substance Use (Describe known history, frequency, type of substance, and date of last use)
Trauma-Related Indicators/Symptoms Observed (Check all relevant)
Hyperarousal/Easily startled
Dissociation/Zoning out
Nightmares/Sleep disturbances
Emotional dysregulation (Severe mood swings)
Difficulty trusting/Forming attachments
Avoidance of specific situations/people
Flashbacks/Intrusive thoughts
Self-isolation
Regressive behaviors
Not Observed/Unknown
Needed Coping Skills and Supports (Check resources needed to support the youth's mental health and stabilization)
Immediate Therapeutic Support (Crisis)
Coping Skills Training (DBT/CBT focus)
Structured Routine/Consistency
Mentorship/Positive Adult Role Model
Peer Support
Medication Management
Cultural/Spiritual Support
Other
Summary of Behavioral/Mental Health Support Plan (Brief plan for initial stabilization)
SECTION 9: Education Information
Current School/Program Name
Grade Level
School District
Key School Contacts (e.g., Counselor, Teacher, Administrator)
Current Enrollment Status
Currently enrolled and attending regularly
Currently enrolled but not attending regularly
Enrolled but pending transfer/start date
Not currently enrolled (Specify reason in notes)
Educational Records Provided During Intake (Check all that apply)
Most recent transcripts/report card
Individualized Education Program (IEP)
504 Plan
Discipline records
Assessment results
Other (Specify below)
Other (Specify below)
If IEP or 504 Plan is checked, what is the current status?
Youth's Academic Strengths, Concerns, and Educational Goals (In the youth's own words, if possible)
SECTION 10: Independent Living & Vocational Information
Life Skills Self-Assessment: Indicate which skills the youth has mastered or feels confident performing independently.
Personal Hygiene and Grooming
Basic Cooking/Meal Preparation
Food Shopping and Nutrition awareness
Laundry and Clothing Care
Basic Money Management/Budgeting
Transportation Access/Use
Making/Scheduling Appointments
Housekeeping/Cleaning
Understanding Lease/Housing documents
Safety in the Community
Has the youth had paid employment history?
Yes
No
If Yes, please provide details (Type of job(s), duration, reason for leaving).
Vocational Interests and Career Goals
Does the youth have any vocational certifications or training (e.g., CPR, Food Handler's Card, specific trade skills)?
Initial Short-Term Goals (e.g., within 3-6 months)
Initial Long-Term Goals (e.g., 1 year+)
SECTION 11: Critical Incidents & History
Summary of Past Critical Incidents/History (Include high-level information relevant to safety and care planning, avoiding graphic details. Focus on patterns or triggers.)
Safety Risks (Check all that apply and describe specifics below)
Risk of Self-Harm/Suicidality
Risk to Others/Aggression
History of Running Away/Absence
Substance Use/Misuse
Sexual Exploitation Risk
Victimization Risk
Fire Setting Risk
Protective Factors (Check all that apply and describe specifics below)
Identified Natural Supports (Family/Friends)
Engagement in School/Work
Coping Skills/Stress Management
Positive Relationship with a Caregiver/Mentor
Healthy Hobbies/Interests
Spiritual/Cultural Connections
Willingness to Engage in Services
Description/Context of Identified Safety Risks and Protective Factors
Describe any noticeable patterns in previous incidents (e.g., triggers, specific times, environments, responses)
SECTION 12: Case & Service Planning
Has the youth been provided with the initial Case/Service/Treatment Plan?
Yes
No
Initial Short-Term Goals for Placement (1-3 weeks):
Initial Long-Term Goals for Placement/Transition (3 months+):
Scheduled Appointments/Engagements (Check all that apply, details must be entered into the calendar)
Medical Appointment Scheduled
Mental Health/Therapy Scheduled
Dental Appointment Scheduled
Educational Meeting Scheduled (IEP/504)
Case Review Meeting Scheduled
Barriers to Success (Check all potential challenges)
Lack of identified supports
Transportation issues
Educational challenges
Mental health symptoms
Physical health issues
Legal involvement
Lack of identification/documents
Supports Needed (Check all essential supports to address barriers)
Trauma-Informed Therapy
Mentorship/Peer Support
Skill Building (Independent Living)
Educational Advocacy Medical/Dental Care Coordination
Access to Legal Aid
Family/Reunification Services
Detailed notes on identified Barriers and Supports Needed
SECTION 13: Intake Observations (Staff Use Only)
Emotional Presentation during Intake
Calm and Cooperative
Anxious/Nervous
Reserved/Guarded
Agitated/Irritable
Distressed/Crying
Flat/Apathetic
Physical Presentation (Choose the best fit)
Clean and Well-Kempt
Needing Hygiene Assistance/Supplies
Evidence of physical discomfort or injury
Appearing restless/Hyperactive
Engagement & Communication Style
Maintained eye contact
Strongly Agree
Agree
Neutral
Disagree Strongly
Disagree
Answered questions clearly
Strongly Agree
Agree
Neutral
Disagree Strongly
Disagree
Appeared engaged and present
Strongly Agree
Agree
Neutral
Disagree Strongly
Disagree
Verbal tone was appropriate
Strongly Agree
Agree
Neutral
Disagree Strongly
Disagree
Notes on Emotional and Physical Presentation, and Communication Observations
Items Brought by Youth (Check all present)
Clothing/Personal Items
Legal/Identification
Documents Medications (Reviewed by Staff)
Money/Valuables (Documented)
School Materials
Contraband/Prohibited Items Identified?
Yes, items were identified and secured/disposed of
No prohibited items found
Details regarding Items Brought and any Contraband/Secured Items
Room Assignment & Orientation Completion
Room Assigned (Specify Room # below)
Tour of facility completed
Staff introductions completed
Initial needs (food, clothing, hygiene) met
SECTION 14: Youth Rights & Orientation Acknowledgment
Youth Rights Explained Checklist (Staff confirmation that each right was reviewed verbally with the youth)
Right to be Safe and Treated with Respect
Right to Privacy and Confidentiality
Right to Access Medical/Mental Health Care
Right to Education
Right to Contact Loved Ones/Advocates
Right to File a Grievance without retaliation
Orientation Items Reviewed (Check all reviewed with youth)
Facility Rules and Expectations
Daily Schedule/Routines
Grievance Procedure Explained
Emergency Procedures (Fire, Lockdown)
Staff Contact Information
Youth Understanding of Rights and Orientation Information
Yes, youth verbally confirmed full understanding.
Partially, youth had questions and needed clarification (Specify below).
No, youth appeared overwhelmed or did not confirm understanding (Specify below).
Notes on Youth Understanding/Clarifications Needed
SECTION 15: Final Signatures & Intake Completion
Intake Completion Date and Time
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Intake Staff Name(s)
Intake Components Completed (Staff confirmation)
All forms/documents received and reviewed
Initial physical assessment completed
Initial safety plan developed
Required notifications made (e.g., placing agency, family)
Intake data entered into electronic record
Follow-Up Actions Required (Check all that need immediate attention)
Urgent Medical/Dental Referral
Immediate Mental Health Assessment needed
Contact School/District within 24 hours
Secure missing identification/documents Other (Specify below)
Notes on Follow-Up Actions
Staff Certification: I certify that the information gathered is accurate to the best of my knowledge and that the youth's rights and orientation materials were reviewed.
I certify this information.
Youth Acknowledgment: I acknowledge that my rights and responsibilities were reviewed with me.
I acknowledge this review.
Intake Staff Printed Name
Youth Printed Name
Case Manager/Worker Printed Name (If present/assigned)
Date of Staff Signature (Signature on hard copy/electronic record required)
MM slash DD slash YYYY
Date of Youth Signature (Signature on hard copy/electronic record required)
MM slash DD slash YYYY
Date of Case Manager Signature (Signature on hard copy/electronic record required)
MM slash DD slash YYYY
Confirmation: Intake packet submission complete. Store securely per policy.
