Laserfiche WebLink
FUNCTIONAL NEEDS INTAKE FORM <br />Date /Time: <br />Shelter Name/City/State <br />Family Last Name: <br />Intake Interviewer may need <br />Primary language spoken in home: <br />assistance with language /interpreter <br />YES /NO <br />Age: <br />❑ male <br />Names /ages /genders <br />❑ female <br />Age: <br />❑ male <br />of all family <br />members present: <br />❑ female <br />Age: <br />❑ male <br />Continue on other <br />side if more room is <br />❑ female <br />needed. <br />Age: <br />❑ male <br />❑ female <br />If alone and under 18, location of next of kin/parent/guardian: If unknown, notify Shelter <br />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, <br />STOP and call for assistance NOW! Or Call 911 <br />Name of <br />COMMUNICATIONS <br />Circle <br />Actions to be taken <br />Individual <br />with Need <br />Will you need assistance with <br />If yes, notify Shelter <br />understanding or answering these <br />YES / NO <br />Manager; refer to <br />questions? <br />Additional <br />Assistance. <br />HEARING <br />Circle <br />Actions to be taken <br />Do you use a hearing aid? Is it with <br />If yes to either, ask <br />YES / NO <br />the next two <br />you? <br />q uestions. <br />Is the hearing aid working? <br />YES / NO <br />If no, identify <br />replacements. <br />Do you need a battery? <br />YES / NO <br />If yes, identify <br />replacements. <br />LANGUAGES <br />Circle <br />Actions to be taken <br />Languages? Sign <br />How do you best communicate with <br />YES/NO <br />language? <br />others? <br />Smartphone? <br />Computer? Other? <br />Speak: <br />What languages can you <br />Read: <br />communicate in? <br />Write: <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachmen3 umber 12 <br />F -6 Page 300 <br />