Intake Assessment

Intake Form

The intake form will be in the form of a questionnaire to collect all the information required. The questions are structured to broaden the topics being discussed rather than have straight forward questions which would mean less interaction.

  1. To each member of the family: Tell me about yourself? This is meant to have everyone in the family state their age, sex, and grade.
  2. To Denise: How would you describe the family setup in terms of structure? (McClennen, Keys and Day, 2016) Does the children’s age influence their responsibilities in the house?
  3. To Denise: How often do you talk to your children regarding their school activities?
  4. To Denise: How have you been fairing at work?
  5. To Denise: How often have you moved in the last five years? Did work-related issues inspire the moving?
  6. To Denise: Could you expound further on the preexisting and current family structure concerning marital status?
  7. To all family members: Have you ever worked with social services before this meeting?
  8. To Denise: What would you identify as the most significant life challenge you’re experiencing at the moment both at home and work?
  9. To the children: What challenges are you experiencing both at school and home?
  10. To Denise: What would you identify as the most pressing need for you to give the family a stable upbringing?
  11. To Denise: What are your thoughts regarding intervention by social services regarding the children’s welfare?


The first referral emanated from Ms. Evans. She is a kindergarten teacher tutoring the youngest family member of the Norris family, Maya. Tertiary referrals were sourced from the teachers and public records. The information regarding Maya’s siblings concerning school activities was derived from their tutors. Chanelle and Robert were tutored by Mr. Jameson and Mr. lee, respectively. School public records were targeted to shed more light on the school performances before joining the Wright Manor School District.

Reasons for Referral

Maya’s deteriorating condition both at school and home, citing poor hygiene and inappropriate behavior. Maya would often come to school looking unkempt, and her posture revealed she was attending school often on an empty stomach. She had been involved in fights with her peers and opened up to Ms. Evans, highlighting the beatings inflicted by her mother. Ms. Evans tried reaching out to Maya’s mother, Denise, to no avail. She initiated phone conversations and also tried sending letters, but neither of the options worked. The failure to establish communication warranted the teacher to contact social services as she believed that it would serve the family with a much-needed boost (Price, Coles, and Wingold, 2017). Chanelle’s reason for referral was absconding school and had been involved in fights within the school parameters. Robert’s case is queer, as the only issue brought forth was his poor communication skills.

Issues to be Addressed

The first issue is the low self-esteem depicted by the family members. Maya and Chanelle quench their self-esteem issues by engaging in fights with their peers while Robert prefers to be alone most of the time. The second issue will be about the flow of communication between the teachers and the mother, Denise. The communication should be seamless as it will help fill information gaps regarding the welfare of the children (Whittaker and Tracy, 2017). The third issue will be Denise’s responsibility towards her children, such as access to basic needs like food and clothing. She is trying her best, but that too is not enough to cater for all the family needs.

Avenues of Resources

The family needs financial support to cater to their basic needs; thus, applying for grants from the government is the best course (Webb, 2018). The grants can be used to cater for accommodation, food, and clothing. The easing up of this burden will encourage the mother to be more involved in the children’s school activities as she will have more time at her disposal. The school counselor will be notified of the predicament and book appointments with the children.




McClennen, J., Keys, A. M., & Day, M. (2016). Social work and family violence: theories, assessment, and intervention. Springer Publishing Company.

Price, S. K., Coles, D. C., & Wingold, T. (2017). Integrating behavioral health risk assessment into the centralized intake for maternal and child health services. Health & Social Work, 42(4), 231-240.

Webb, N. B. (2018). Social work practice with children. Guilford Publications.

Whittaker, J. K., & Tracy, E. M. (2017). Family preservation services and education for social work practice: Stimulus and response. Reaching High-Risk Families: Intensive Family Preservation in Human Services-Modern Applications of S

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