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Initial Contact and Screening Form
Initial Contact and Screening Form
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Foundations Family Services — Initial Contact and Screening Form
Required by 12VAC35-105-645
Date of Initial Contact
Section 1: Individual Information
Full Name
Preferred Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Email if applicable
Address
Legal Guardian if applicable
Emergency Contact Name & Phone
Section 2: Referral Source
Referral Source
Self
Family Member
Case Manager / Support Coordinator
Hospital / Facility
Other
Other Referral Source
Name of Referring Party
Contact Information
Section 3: Service Request Type
What services are being requested?
Group Home
Community Engagement / Day Support
In-Home Services
Behavioral Health Support
Other
Other Service Requested
Section 4: Screening Questions
Is the individual currently receiving services from another provider?
Yes
No
Does the individual have a current support coordinator?
Yes
No
Are there known medical or behavioral needs?
Yes
No
Does the individual require 24-hour supervision?
Yes
No
Does the individual have a current Medicaid Waiver?
Yes
No
Is there a legal guardian or power of attorney in place?
Yes
No
Any safety concerns we should be aware of?
Yes
No
Primary Language Spoken
Section 5: Notes from Screening
Staff should summarize needs, eligibility concerns, next steps, or reasons for non-acceptance.
Section 6: Outcome of Initial Screening
Outcome
Referred to Intake Team for Assessment
Not Eligible – Referred to Other Resources
Waiting List
Declined by Individual or Guardian
More Information Needed
Name of Staff Completing Form
Title
Date Completed
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