Fillable Printable Form 5553
Fillable Printable Form 5553
Form 5553
Page 1 of 3
INTAKE QUESTIONNAIRE
State Form 55538 (3-14)
FAMILY AND SOCIAL SERVICES ADMINISTRATION
Please complete the DHHS IIP intake form first. All questions must be answered and completed by the Case Manager.
Name of consumer Date (month, day, year)
Method of intake
Walk-in Videophone Other: ________________________________________________________________________
Consumer’s requested services
Case Manager’s observations
GENERAL ABILITIES
FUNCTIONAL LEVEL
NOTES
Dependent
Needs
assistance
Independent
Not
Applicable
Vocational (ability to use job-searching skills,
job-oriented skills, employment resources,
Vocational Rehabilitation, etc.)
Living Situation (family stress, rooming issues,
family crisis, etc.)
Legal Assistance (obtaining the pro-bono
services for housing, welfare, social, job
discrimination / employment, economic,
disability, benefits, immigration, etc.)
Transportation (ability to use public
transportation, taxi, special fares, application
form, etc.)
Assistive Technology (visual alerting devices –
doorbell, fire alarm, phone flasher, videophone,
phone with amplifier, etc.)
Interpersonal Skills (ability to communicate,
able to use problem-solving skills, facial and/or
body language expressions, etc.)
Decision-Making Skills (use judgment; logistics;
personal experiences, attitudes, and perceptive;
problem analysis; possible consequences;
priority of choices; able to diffuse conflict
disputes; intellectual / mental process of
understanding and reasoning in knowledge; etc.)
Resource Needs (how to access services
community for food, housing, job opportunities,
etc.)
Communication Access (obtain interpreting /
CART services, know their rights for
communication accommodations, able to self-
advocate for effective communication
accommodation, etc.)
Housing Needs (apply for low-cost housing
assistance, understand the rent based on
his/her incomes)
Insurance (understand his/her insurance
coverage, prescription coverage, premiums,
required spend-down fees, etc.)
Reset Form
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(continued)
GENERAL ABILITIES
FUNCTIONAL LEVEL
NOTES
Dependent
Needs
assistance
Independent
Not
Applicable
Communication barrier (alternative methods for
communication such as paper / pen; I-Pads –
Dragon Dictation, Text to Text, etc.; Video
Relay Services, gestures, etc.)
Support System (reliable support from family
members, friends, colleagues, professionals for
his/her survival or growth, etc.)
Trauma* (understand the reason and/or
symptoms why you become upset or angry, able
to get help managing daily life issues by using
medicines, counseling, or support group, etc.)
Self-advocacy and interact into the community
Child Care (ability to find resources for your
children to be placed for childcare before you
become "employed", and able to evaluate your
child if he/she is ready to be home alone –
basic agreement, safety issues, necessary
information, and safety hints
Additional Disabilities (by birth or accident later
in adult life, get familiar what you or your
children have and be able to get resources for
advocacy for any kind of accommodation, if
applicable)
Other:
* Characteristics of the trauma experience (sexual abuse, physical abuse, emotional abuse, medical trauma, natural disaster, witness to family violence,
community violence or criminal actions)
LEVEL OF FUNCTIONING –
ABILITY TO PERFORM BASIC
LIVING SKILLS (if applicable)
DOES THE CONSUMER
NEED ASSISTANCE?
TYPE OF
ASSISTANCE NEEDED
SOURCE OF
ASSISTANCE RECEIVED
House Cleaning – Follow daily routine
(vacuuming, cleaning common areas,
emptying trash containers)
Yes No
Self-Care – Ability to take care of
personal health and/or hygiene; stay
healthy and mentally fit by eating well
and exercise, etc.
Yes No
Household Maintenance (unclogging
toilet, changing light bulbs, etc.)
Yes No
Nutritional Skills – Familiarize with basic
food needs, able t o read the b asic
nutritional facts shown on the b ox, know the
difference betw een junk and hea lthy foods,
and familiar with a balanced me al plan, etc.
Yes No
Laundry – Ability to use the washing
machine, using right detergent, folding
and putting clothes away, etc.
Yes No
Grocery Shopping – Make a weekly
menu, list ingredients that you verified
need to purchase, create grocery list
(produce, bakery, canned goods, cereals,
meats, dairy, frozen foods, beverages,
and snacks), use coupon, etc.
Yes No
Page 3 of 3
(continued)
LEVEL OF FUNCTIONING –
ABILITY TO PERFORM BASIC
LIVING SKILLS (if applicable)
DOES THE CONSUMER
NEED ASSISTANCE?
TYPE OF
ASSISTANCE NEEDED
SOURCE OF
ASSISTANCE RECEIVED
Medication Management – Ability to
identify medications and purpose,
organize medication for daily use, contact
doctor for refills or follow-up appointment
if necessary
Yes No
Money Management – Maintains
checking / savings accounts, manages
monies – i.e., counting monies, make
changes, purchase responsibly – i.e.,
paying monthly bills and large purchases,
evaluates cost of services (banking, bills,
credit cards, and loan) etc.
Yes No
Telephone Communication – Able to use
phone, TTY, VP: Point-to-Point, VRS,
Cap-Tel, etc.
Yes No
INCOME / EARNINGS STATUS (check one) AMOUNT INSURANCE
Employer
Yes No Pending $
Please check one or more if you have:
SSD
Yes No Pending $
SSI
Yes No Pending $Medicaid: Yes No Pending
Food Stamps (SNAP)
Yes No Pending $Medicare: Yes No Pending
TANF
Yes No Pending $Employer: Yes No Pending
Unemployment
Yes No Pending $ Self: Yes No Pending
VA Benefits
Yes No Pending $Dependent: Yes No Pending
Housing Assistance
Yes No Pending $
Utility Assistance
Yes No Pending $None: Yes No
Other: _____________
Yes No Pending $
Total
$
Create for POA (Plan of Action)
1. Community – Use of public transportation, videop hone service, available resources in the community, personal identification awareness, housing,
how to use interpreting service, job search opportunities, Driver's Education course, retirement, obtaining documentation verification such as birth
certificate, etc.
2. Health – Dental, medical issues, medical equipment, and nutritional needs related to medical care, family planning, cancer / diseases, aging,
emergency services, death or life-changing situations, etc.
3. Home – Personal/hygiene care, ADL (Activities of Daily Living), banking, budgeting, shopping, grocery shopping, clothing needs, laundry,
household cleaning, financial needs, mobility, housing, deaf-related devices, etc.
4. Social Service – Insurance (car, home, health), legal, employment, school, Social Security benefits, Medicaid / Medicare, advocacy, BMV,
Vocational Rehabilitation Services, Unemployment Benefits (Department of Workforce Development), etc.
5. Social Skills – Coping skills, anger, communication breakdown, lack of communication, limited MLS (minimum language skill), conflict with
employer or family member, poor boundary issues, e-mail etiquette, etc.
Consumers requiring one (1) time service: be sure to complete service and close case, and documentwhy it is a one (1) time service.
