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FUNCTIONAL NEEDS INTAKE FORM <br />Date/Time:----Shelter <br />Name/City/State <br />Family Last Name: <br />Intake Interviewer may need assistance with <br />Primary language spoken in home: <br />language /interpreter YES/ No <br />Age: <br />LL male <br />LL female <br />Names /ages /genders <br />Age: <br />LL male <br />of all family members <br />LJ female <br />present: <br />Age: <br />LL male <br />Continue on other side if <br />LJ female <br />more room is needed. <br />Age: <br />LL male <br />LL female <br />If alone and under 18, location of next of kin /parent /guardian: If unknown, notify Shelter Manager & interviewer initial here: <br />Home Address: <br />Client Contact Number: <br />Interviewer Name (print name): <br />Signature: <br />DO YOU HAVE A MEDICAL OR SAFETY CONCERN OR ISSUE RIGHT NOW? If yes, STOP and call <br />for assistance NOW! Or Call 911 jW <br />Name of Individual <br />COMMUNICATIONS <br />Circle <br />Actions to be taken <br />with Need <br />Will you need assistance with understanding or <br />If yes, notify Shelter Manager; refer <br />answering these questions? <br />YES / NO <br />to Additional Assistance. <br />HEARING <br />Circle <br />Actions to be taken <br />If yes to either, ask the next two <br />Do you use a hearing aid? Is it with you? <br />YES / NO <br />questions. <br />Is the hearing aid working? <br />YES / NO <br />If no, identify replacements. <br />Do you need a battery? <br />YES / NO <br />If yes, identify replacements. <br />LANGUAGES <br />Circle <br />Actions to be taken <br />Languages? Sign language? <br />How do you best communicate with others? <br />YES / NO <br />Smartphone? Computer? Other? <br />Speak: <br />Read: <br />What languages can you communicate in? <br />Write: <br />If yes, notify Interpreter Strike <br />Do you need a sign language interpreter? <br />YES / NO <br />Team Leader <br />VISION /SIGHT <br />Circle <br />Actions to be taken <br />If no, ask if they need a <br />Do you wear eye glasses? Are they with you? <br />YES / NO <br />replacement? <br />Do you have difficulty seeing, even with glasses? <br />YES / NO <br />If no, skip to the next section <br />Do you use a white cane? Is it with you? <br />YES / NO <br />If yes, ask next questions <br />If yes, collaborate with Functional <br />Do you need help getting around, even with your <br />Needs Support Services (FNSS) <br />white cane? <br />YES NO <br />/ <br />Advisor and Regional Shelter <br />Supervisor. <br />Name of Individual <br />MEDICAL <br />Circle <br />Actions to be taken <br />with Need <br />Do you have any severe allergies? <br />YES / NO <br />If yes, refer to Health <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachmentnnumber 12 <br />F -6 Page 288 <br />