Multidisciplinary Team Intake Form
Multidisciplinary Team Intake Form
| Client Information | |||||
| Name | Age | Race/ethnicity | Gender | Primary Language | Disability/Special Needs |
| Carmen McKensy | 10 | Latina-White | Female | English | none |
| Caregiver Information | |||||
| Name | Age | Gender | Relationship to client | ||
| Maria McKensy | 30 | Latina | Female | Mother | |
| Client’s Family and Noted Individuals | |||||
| Name | Age | Gender | Relationship to client | ||
| Sara McKensy Gregg McKensy | 67 69 | White | Female Male | Grandmother Grandfather | |
| Address | |||||
| 1234 Poorly Kept Neighborhood, Indiana PA | |||||
| Alleged Perpetrator(s) | |||||
| Name | Age | Gender | Relationship to client | ||
| Tom McKensy | 35 | White | Male | Father | |
| Address | |||||
| 1234 Poorly Kept Neighborhood, Indiana PA | |||||
| Allegation Information | |||||
| Type of abuse | Neglect of education, insufficient food, small for age | ||||
| Circumstance of disclosure | School Principal Horace Mann Elementary School Observations | ||||
| Geographic location where alleged abuse occurred | 1234 Poorly Kept Neighborhood, Indiana PA | ||||
| Description of allegations | |||||
| Carmen is small for her age. She searches for food discarded by other children. She doesn’t complete her homework. | |||||
| Referent Information | |||||
| Referral Source | School Principal | ||||
| Additional professional(s)/ Agency(ies) | Carmen’s teachers all indicate she is respectful but doesn’t pay attention well or complete assignments. Child Protective Services doing investigation. | ||||
| Medical Information | |||||
| Has the client had a medical examination regarding the current allegations? | £ Yes £X No £Unknown at intake | ||||
| If so, where? | |||||
| Who will bring the client to the Interview? | Family interviewed at home. |
