Social Work Intake Form Template – US

Important Notice

This document serves as a standard intake form used in community and healthcare settings to gather essential information from individuals seeking support services. It is provided for general informational purposes and should not replace professional assessment or legal advice. The specific questions and procedures may vary depending on the organization or jurisdiction. Users are responsible for ensuring compliance with applicable policies and regulations. The use of this template is at the user’s own risk, and no liability is assumed for inaccuracies or misuse without appropriate customization and review by qualified professionals.

Please note: This is a sample Social Work Intake Form for the US, provided here for illustrative purposes only. Actual forms may vary according to agency requirements and legal standards.

Social Work Intake Form Sample (US)

Client Information:

Name: ________________________________
Date of Birth: __________________________
Address: ________________________________
Phone Number: ___________________________
Email: _________________________________

Presenting Concerns:

Please describe the main reasons for seeking social work services: ________________________________
____________________________________________________________

Family and Social History:

Brief overview of family background, social relationships, and support systems: ________________________________
____________________________________________________________

Medical and Mental Health History:

Relevant health information, current medications, mental health conditions: ________________________________
____________________________________________________________

Goals for Service:

Client’s objectives and expectations from social work intervention: ________________________________
____________________________________________________________

Consent:

I agree to participate in the social work process, understanding my rights and confidentiality policies.

Social Worker:

Name: ________________________________
Agency: ________________________________
Contact: ________________________________

Date of Intake: ________________________________