Missouri AgrAbility
SIL INTAKE INFORMATION Form
Date: ____________________
SIL Case #: _________________
Name: __________________________________________________________________
Address: ________________________________________________________________
City: _______________________ ,MO
Zip: ___________ County: ______________
Home Phone: _________________________ Work Phone: _______________________
DOB: _____/____/_____ SS#: _________________ Primary ICD 9: ______________
Marital Status: S M D W Sep Sex: M
F
Race: C AA H NA A PI
Emergency or other
Contact Person: __________________________________ Phone: _________________
Relationship: ___________________________________
Primary Disability: ______________________________ Onset: ___________________
Source of Income: ________________________________ Amount/Month: __________
Referred By: _________________________________ Agency: ___________________
Medicaid #: __________________________ Medicare #: ________________________
Spenddown:
Y
N If Y, what amount ______________ How met: _______________
Other Insurance: __________________________________________________________
Other Agencies involved at time of Intake
Contact Person or Counselor
Regional Center or BCGH/FS ___________________________________________
DVR or RSB
___________________________________________
Division of Family Services
___________________________________________
Division of Aging
__________________________________________
Consumer Request at Intake: ________________________________________________
________________________________________________________________________
ILS: ______________________________________________
INTAKE INTERVIEW NOTES
ADDITIONAL INFORMATION
Head of Household: Y N
# of Children: ________
Veteran: Y N
Add to SIL mailing list: Y N
# in Household: _________ Accessible House: Y N
Disability: If Multiple—please indicate by order of significance using 1 as primary #
Amputation _____
Arthritis _____
Psycho-Neuro Disorder _____
Vision Impairment _____
Cerebral Palsy _____
Chronic Condition _____
Congenital Disorder _____
Multiple Sclerosis _____
Neuromuscular _____
Spinal Cord Injury _____
Mental Retardation _____
Other Orthopedic_____
Unknown _____
Non-disabled _____
Deaf/Hard of Hearing _____
Degenerative Disorder _____
Diabetes _____
Epilepsy/Seizure Disorder _____
Traumatic Brain Injury _____
Heart/Respiratory _____
Developmental Disability _____
Muscular Dystrophy _____
Polio/Post Polio _____
Stroke _____
Substance Abuse _____
Other Mental Impairment _____
Family Member _____
*** Indicate Onset of each if possible
Other description of disability if necessary: ____________________________________
_______________________________________________________________________
Service Requests
___ Advocacy
___ IL Skills Training
___ Transportation
___ Assistive Technology
___ Home Modifications
___ AgrAbility
___ PAS
___ Shopping
___ Support Groups or Peer Support
___ Housing
___ Ramps
___ Telecommunications Access Program
Links to other services:
___ Social Security ___ Food Bank ___ DFS ___ DVR ___RSB ___MC+
Other: _____________
Education Completed: _____________________________________________________
Previous Contact with CIL? Y N CIL name or city: ____________________________
Directions to consumer’s residence (detail directions if needed or attach internet map)
________________________________________________________________________
________________________________________________________________________
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