About this template
A Case Management Intake Form is a critical tool for gathering comprehensive client information, which is essential for effective care planning and service delivery. This form supports the initial assessment, coordination, and monitoring of client needs, ensuring that organizations can provide tailored, efficient, and well-documented support from day one.
Designed specifically for social workers, caseworkers, and human service agencies, this template provides a structured format for collecting personal details, emergency contacts, medical history, socioeconomic background, and primary case goals. By organizing this critical data upfront, practitioners can streamline their intake workflows, minimize redundant questioning, and establish a clear roadmap for client success.
With Doc2Form, you can instantly convert this template into a fully customizable Google Form. Easily share the link with incoming clients or fill it out during initial consultations, keeping all intake records neatly organized in Google Sheets for effortless tracking and team collaboration.
Key features
- Capture complete client demographic and emergency contact details in one submission.
- Document presenting issues, medical history, and socioeconomic background.
- Set clear case management goals and desired client outcomes early.
- Streamline intake workflows with a clean, mobile-friendly Google Form layout.
- Automatically organize all client responses in a secure Google Sheets spreadsheet.
Use cases
Social work agencies onboarding new community support clients.
Nonprofit organizations tracking program participants and service req…
Nonprofit organizations tracking program participants and service requests.
Mental health clinics gathering patient background before initial con…
Mental health clinics gathering patient background before initial consultations.
Case managers coordinating multi-agency care plans for vulnerable ind…
Case managers coordinating multi-agency care plans for vulnerable individuals.
What this form collects
- Date of Intake (Date)Select today's date.
- Case Number (Short answer)Leave blank if this is your first visit or you do not have an assigned case number.
- Full Legal Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Gender (Dropdown)Select the option that best describes how you identify.
- Home Address (Paragraph)Provide your current street address, city, state, and zip code.
- Email Address (Short answer)Enter a reliable email address for ongoing communication.
- Phone Number (Short answer)Include area code.
- Emergency Contact Name (Short answer)Name of a trusted friend or family member we can reach in an emergency.
- Emergency Contact Relationship (Short answer)E.g., Spouse, Parent, Sibling, Friend.
- Emergency Contact Phone Number (Short answer)Primary phone number for your emergency contact.
- Referred By (Short answer)Name of the person, agency, or organization that referred you to us.
- Reason for Referral (Paragraph)Briefly describe why you are seeking services at this time.
- Presenting Issues Description (Paragraph)Detail the main challenges or concerns you are currently facing.
- Issue Duration (Multiple choice)How long have you been experiencing these challenges?
- Prior Help Status (Multiple choice)Have you received professional help or case management services for these issues before?
- Prior Help Details (Paragraph)If yes, please describe the previous services and whether they were helpful.
- Primary Physician Name (Short answer)Name of your current primary care doctor or clinic.
- Current Medications (Paragraph)List any prescription medications, dosages, or supplements you are currently taking.
- Allergies (Paragraph)List any known drug, food, or environmental allergies.
- Medical Conditions (Paragraph)List any chronic or significant medical conditions.
- Mental Health History (Paragraph)Describe any past or current mental health diagnoses, counseling, or treatments.
- Marital Status (Dropdown)Select your current marital or relationship status.
- Living Situation (Short answer)Describe your current housing arrangement (e.g., renting, own home, staying with family, shelter, unhoused).
- Current Employment Status (Dropdown)Select your current employment situation.
- Highest Level of Education (Dropdown)Select the highest grade or degree you have completed.
- Source of Income (Dropdown)Select your primary source of financial support.
- Case Management Goals (Paragraph)What specific goals do you hope to achieve through our case management program?
- Desired Outcomes (Paragraph)What does success look like for you at the conclusion of these services?
- Additional Information (Paragraph)Share anything else you would like your case manager to know.
- Intake Officer Name (Short answer)Name of the staff member completing or reviewing this intake.
- Client Signature (Short answer)Please type your full legal name to confirm the accuracy of the information provided above.
- Signature Date (Date)Select today's date.
FAQ
What is a case management intake form?
It is an assessment tool used by social workers and caseworkers to collect essential background, medical, and demographic information from new clients before starting support services.
Can I customize the questions in this Google Form template?
Yes! Once you generate the form using Doc2Form, you have full ownership in Google Forms to add, remove, or modify any questions to fit your specific program requirements.
Where does client data go when submitted?
All responses are automatically populated into a connected Google Sheets spreadsheet, giving your team a secure, centralized workspace to review and manage client files.
Is this form mobile-friendly for clients?
Google Forms automatically formats your intake questionnaire for smartphones, tablets, and desktop computers, ensuring clients can complete it from any device.
How do I share this intake form with clients?
You can share the Google Form via a direct link, embed it on your organization's website, or email it to clients prior to their scheduled intake appointment.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.