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.

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Multidisciplinary Team Intake Form

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