• SLS

    Assessment Intake Form
  • Is this an Initial Assessment or the Final Report
  • Format: (000) 000-0000.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Assessment Referrel Overview

    This assessment was requested by at SCLARC. Service Coordinator and agreed that additional assistance is needed to support life management skills and daily living and self-advocacy. The overall goal is to assist with developing and implementing plans, and providing resources that will enable him/her to conduct and accomplish all goals/responsibilities.

    Findings are based on but not limited to review of visual observation, IPP/Medical, CDER, Psychological reports, etc. SLS Services will be employed to achieve the following: Securing housing, support in working to learn appropriate techniques/skills, learn healthy relationships, money management/budgeting, household utilities, grocery shopping, meal preparation, emergency procedures, personal health, life management, appropriate socialization, self-care, accessing generic resources, etc. Additionally,     will work to take responsibility for making life decisions based on preference that enhance the prospects for increased independence, self-reliance, self-esteem and for implementing those decisions effectively.

  • Participant Current Situation

       is a -year-old    adult.    is diagnosed with moderate intellectual disability.    would like assistance with daily living and routine needs to be as independent as possible.

  • Is there a gender preference regarding the assigned staff?
  • 1. Does Participant receive SSI?
  • 2. Does Participant have any Judicial Involvment or History of Violence?
  • 3. Does Participant want assistance with grooming/hygiene/dressing?
  • 4. Does Participant attend to their household chores including doing laundry?
  • 5. Are you actively being seen by Medical professionals (Primary Physician, Dentist, etc.)
  • 6. Does the Participant want instruction and support with cooking/preparing their meals?
  • 7. Does the Participant want instruction and support with comparative shopping?
  • 8. Have you ever used any controlled substances? Do you feel you have an addiction? (Marijuana, Meth, Crack Cocaine, Mushrooms, Ecstacy, etc.)
  • 9. Does the Participant ever feel afraid of their partner or someone in their life?
  • Should be Empty: