Multidisciplinary Team Intake Form

Multidisciplinary Team Intake Form

 Client Information
NameAgeRace/ethnicityGenderPrimary LanguageDisability/Special Needs
Carmen McKensy10Latina-WhiteFemaleEnglishnone
 Caregiver Information
NameAge GenderRelationship to client
Maria McKensy30LatinaFemaleMother
 Client’s Family and Noted Individuals
NameAge GenderRelationship to client
Sara McKensy Gregg McKensy67 69WhiteFemale MaleGrandmother Grandfather  
 1234 Poorly Kept Neighborhood, Indiana PA
 Alleged Perpetrator(s)
NameAge GenderRelationship to client
Tom McKensy35WhiteMaleFather
 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.
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