Intake Form

START STAGE 1: CONTACT INFORMATION: TIME GOAL <20 MINUTES

Date:
Intake rep.:
Caller Name:
Emergency (circle one): Yes or No
Is Caller Patient?:
Caller Phone:
Caller Email:
Patient Name:
Patient Birth Date:
Situation – General:
Description of Problem:

Resolution

Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Parties Involved and Their Roles:
Parties Involved and Their Roles:
Parties Involved and Their Roles:
Parties Involved and Their Roles:
Goal or Desired Outcome (Primary):
Goals or Desired Outcomes (Secondary):
Goals or Desired Outcomes (Secondary):
Health Insurance:
Stress Level (1 to 10):
Access to Primary Care:
Situation – Detail:
How Problem Impacts Patient:
Confirmation with Caller of Key Issue:
Medical Diagnosis:
History of Key Issue :
Related Problems:
Access to Support:
Description if “N”:
Access to Transportation:
Description if “N”:
Access to Safe Housing:
Description if “N”:
Access to income:
Description if “N”:
Access to Nutrition:
Description if “N”:
Current Employment:
Description if “N”:
Access to Medical Records:
Description if “N”:
Client Question List:
Client Contact Preferences:
Client Backup Contact Method:
Release of Medical Information Under HIPAA Needed:

Create Client Record in CRM

END STAGE 1: INITIAL CONTACT: TIME GOAL <20 MINUTES

START STAGE 2: ASSESSMENT & RESOLUTION PLAN

Assign & notify team lead in CRM

Research how others have solved the key issue.
Identify / document needs & resources
Review data and guidelines on key issue resolution
Identify possible solutions and the people involved
Draft Next Step Resolution Plan (NSRP)
Document NSRP in Client CRM

END STAGE 2: ASSESSMENT & RESOLUTION PLAN

START STAGE 3: INITIAL EXECUTION

Re-engage Caller:
Identify Changes to Primary Problem and Situation:
Review NSRP “Key Recommendations”:
Affirm Primary Goal:
Communicate Possible Solutions:
Identify Client Questions:
Answer Questions:
Chosen solution:
Document each party’s roles:
Review / Document “Next Steps” Plan (with dates):
Agree on closing the loop on actions:

END STAGE 3: INITIAL EXECUTION

START STAGE 4: PROCESS CONTINUATION

Action Items- Solution Implementation:
Complete Agent and Liability Forms:
Begin implementing solutions:
Create Care Team in CRM:
Identify plan to monitor progress:
Begin Plan Implementation:

Document Each Action Taken in Care Coordination Platform
Close Case at Goal (Row #25) Attainment

END STAGE 4: PROCESS CONTINUATION 

STAGE 5: DATA ANALYSIS & PERFORMANCE EVALUATION