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It also structures key sections for daily routines, concerns, priorities, strengths/resources, social history, family preferences, next steps, and follow-up responsibilities, with signature and title fields.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/template-for-intake/168453/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/template-for-intake/168453.png","ImageObject",442,249,{"name":42,"@type":43},"Gelato","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-09-27","2026-09-01",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What information should be recorded in the Intake template?","Question",{"text":62,"@type":63},"Include date/time, meeting participants and roles, meeting environment, information shared/discussed, information gathered, documentation completed (forms/consents and what was approved or declined), and any items still pending via Docusign.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How should the template handle consents and documentation workflow?",{"text":67,"@type":63},"List all reviewed forms/consents and document what the family consented to or declined, along with what is still waiting via Docusign. The examples also describe sending or collecting copies for confidentiality, releases of information, and required notices.",{"name":69,"@type":60,"acceptedAnswer":70},"What sections capture a family’s needs and the plan after intake?",{"text":71,"@type":63},"Use Highlights for daily activities and routines, then record family concerns, priorities, strengths/resources, social history/family assessment summary, and preferences (contacts, times, locations, evaluators). Finally, document next steps and follow-up activities with who will do what and by when, plus the SC signature and title.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},168453,1788231744,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":22},19241457091524,"https://us-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Intake\nThis resource focuses on documentation related to an intake meeting.  It is important to keep in mind that every family is unique.  While some of the items documented will be consistent across contacts, many pieces of information will all be specific to the family.\nThe following template may be customized for individual use.  Areas in italics can be replaced with your details.\nTemplate for Intake\nDate/Time:\nPeople Participating in Meeting: include their name and role/relationship to the child\nMeeting Environment:\te.g., in person at the child/family home, Live Video Visit (LVV) via a secure connection through Microsoft Teams or Zoom\nInformation Shared/Discussed: e.g., EI philosophy/model, principles of early intervention, family’s role in EI, the SC’s role in EI, education on how EI is different from the medical and educational models, the EI process, timelines, family rights, privacy laws, forms/consents/documents, how to use/sign via Docusign, use of insurance, family participation fee schedule, provider selection, EI Clearinghouse resources shared, transition resources, etc.\nInformation Gathered: e.g., check for understanding on referral Information, obtain birth/medical history, health status, complete screenings (ASQ: SE2, All Kids/DSCC, etc.), family assessment, etc.\nDocumentation Completed: list all forms/consents reviewed, what the family consented to and/or declined, and what you might still be waiting for via Docusign\nHighlights:\nDaily Activities and Routines family seeks support with:\nFamily Concerns:\nFamily Priorities:\nFamily Strengths/Resources:\nRBI/Intake Social History/Family Assessment Summary:\nFamily Preferences: e.g., primary contact, preferred contact method, days of week, times of day, location of evaluations, preferred evaluators/providers, etc.\nNext Steps and Follow-up Activities: include details about who will do what and by when\nSC signature and title:\nExamples of Intake\nThe following provides examples of the level of detail that should be included in a case note documenting the discussion and activities completed at intake.\nExample of Intake #1\nEI\nThis writer completed an intake in the family’s home with [insert parent/guardian role/name] provided [insert parent/guardian]  with an overview of the Early Intervention system and gave parent/guardian a copy of “The Illinois Early Intervention Program: A Guide for Families”. Parental rights were also reviewed with the parent/guardian and the parent/guardian was given a copy of “State of Illinois Infant/Toddler & Family Rights Under IDEA for the Early Intervention System”. Parental Consent and Ability to Decline Services was reviewed with parent/guardian and consent was given for a Family assessment.  Parent/Guardian also consented for an initial evaluation. The Routine Based Interview, ASQ-SE2, and birth and medical history were completed with the parent/guardian. Summarized information with parent/guardian on Family Assessment form and entered in section 1 of AS03.\nThe following are the child and family’s strengths, concerns, and priorities [insert list of priorities here]. Discussed EI Evaluators and Natural environments with parent/guardian and evaluators were selected [insert evaluator preferences]. Reviewed and gave parent notice of Confidentiality Practices and parent signed consent to Collect, Store, and Utilize PII. Parent/Guardian signed releases of information to/from Pediatrician [list name], EI Providers [list each one], and the local school district [insert district if/when applicable].  Discussed release of information to the referral source [e.g., insert physician, health department, childcare center, etc.] and obtained consent to share initial evaluation reports and IFSP if developed to the referral source.\nParent/Guardian signed Social Security Disclosure, declining to share their social security number at this time. All Kids/DSCC screening was completed with parent/guardian and child [insert results of screening]. Parent signed relea","cbCaieV6z53MrTed","https://ap.wps.com/l/cbCaieV6z53MrTed","docx",24718,"English","# Intake\n## Template Sections\n## Examples of Intake","[{\"question\":\"What information should be recorded in the Intake template?\",\"answer\":\"Include date/time, meeting participants and roles, meeting environment, information shared/discussed, information gathered, documentation completed (forms/consents and what was approved or declined), and any items still pending via Docusign.\"},{\"question\":\"How should the template handle consents and documentation workflow?\",\"answer\":\"List all reviewed forms/consents and document what the family consented to or declined, along with what is still waiting via Docusign. The examples also describe sending or collecting copies for confidentiality, releases of information, and required notices.\"},{\"question\":\"What sections capture a family’s needs and the plan after intake?\",\"answer\":\"Use Highlights for daily activities and routines, then record family concerns, priorities, strengths/resources, social history/family assessment summary, and preferences (contacts, times, locations, evaluators). Finally, document next steps and follow-up activities with who will do what and by when, plus the SC signature and title.\"}]","Template for Intake | DOCX"]