STF Intake
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Morlock Foundation, Inc.
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STF Client Intake & Checklist
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REFERRED BY:
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ID #
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NOTES FOR INTAKE
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First NameLast
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Date of BirthDiagnosis
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Address
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CityState, Zip
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PhoneCell Phone
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Email
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DO NOT PUT THE EMAIL ADDRESS IN THE SLOT ON PRACTICE FUSION DUE TO THE FACT IT WILL SEND EMAILS WITHOUT YOU KNOWING. PUT EMAIL ADDRESS IN THE NOTES SECTION OF THE BASIC INFO PAGE.
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Questions:
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1. We would like send the paperwork via email, can I do that?
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2. Any children in the house? Can I get the names and ages please
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3. What needs are you hoping we can help you with?
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4. Have you or any members of your household served in the military?
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5. Can you tell me what traumas have brought you to call for help today? Some examples are: Disease, disability, lacking of basic needs, house fire, elderly/fragile, domestic violence.
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We have to have a trauma to be able to work with you so can you help me to come up with why you came for help today.
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6. I am going to read you some information to help answer some questions.
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We do not distrube any money, but we work hard on your behalf to make sure your needs are met, and apply for grants that you might be eligible for. Everything we receive is a donation. There is no gaurentee if it will be new or used. However, there is no guarantee, but we do again to our best to try to gain a positive outcome for you. Intake sign initals in box to left
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We will assist you in finding housing, but we do not help you with secuirty deposits. You can obtain a voucher at the department of social serivces. We can also assist in helping you find a place that takes the vouchers. Intake Sign initals in box to left
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We will be sending you the paperwork and we must have the paperwork signed and returned in order to be able to start helping work with you to meet your needs. Intake sign initals in box to left
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We assist in finding the needs of the client. We do not bring those items into the home. (An example is if someone is in need of a couch and we find that for them and deliver it.) There is no guarantee it will be delivered, you may have to pick it up. If delivered we will NOT be taking it into the home. Intake sign initals in box to left
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The process here is 1. we do this intake 2. we send the paperwork to you 3.upon returning the paperwork we assign you a case manager who will then give you a call and introduce themselves and set up an appt. to go through the currently told us about and start working to try and meet your needs. assessment to make sure that there are not other needs you may have that you have not have told us about. Intake sign initals in box to left
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If something is not spelled out in writing, please make sure to ask the process. We do not assume anything nor responsiblity for what is not spelled out. Intake sign initals in box to left
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Do you have any questions for me or anything you would like me to note on here for the case manager that you will be assigned to? Intake sign initals in box to left
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I have one last thing before we hang up, are the phone number and address that you provided me with ok for us to use to contact you? The reason I ask is sometimes we are working with Domestic Violence and we do not want to endanger anyone. Yes or No
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IF NO, how do we get ahold of you then? Intake sign initals in box to left
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Please feel free to call us at 716-842-1300 if you should have any questions. Our fax number is 716-249-3388.
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SIgn here ___________________________ and give this sheet to JessicaDATE: _____________
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