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Case Management Intake Form

Case Management Intake Form Template for New Zealand

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Key Requirements PROMPT example:

Case Management Intake Form

"I need a Case Management Intake Form for our mental health service provider in Auckland, with emphasis on cultural sensitivity and Māori health perspectives, to be implemented by March 2025."

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Document background
The Case Management Intake Form is a crucial document used in New Zealand's health and social services sector to initiate client services and gather comprehensive information for effective case management. This document is designed to comply with New Zealand's regulatory framework, including the Privacy Act 2020, Health Information Privacy Code 2020, and relevant healthcare service standards. It is typically used during the first interaction with a client to collect essential information about their needs, circumstances, and support requirements. The form includes sections for personal information, health status, cultural considerations, and risk assessment, forming the foundation for developing personalized care plans and coordinating appropriate support services.
Suggested Sections

1. Personal Information: Basic client details including name, date of birth, contact information, and preferred contact method

2. Emergency Contact Details: Information about primary and secondary emergency contacts

3. Cultural Information: Cultural identity, iwi affiliations if applicable, language preferences, and any cultural considerations

4. Current Living Situation: Housing status, living arrangements, and household composition

5. Health Information: Current health status, medical conditions, medications, and treating healthcare providers

6. Primary Needs Assessment: Main reasons for seeking case management services and immediate concerns

7. Current Support Services: Existing support services, including medical, social, and community support

8. Privacy Statement and Consent: Information about how personal data will be used and stored, and consent for information sharing

9. Risk Assessment: Initial assessment of any immediate risks or safety concerns

Optional Sections

1. Mental Health History: Details of mental health conditions and treatment history - include when mental health support is identified as a need

2. Disability Support Needs: Specific disability-related information and support requirements - include when client has disability support needs

3. Income and Financial Information: Financial situation and support needs - include when financial assistance or budgeting support is required

4. Legal Status: Information about any legal orders or proceedings - include when legal issues are present

5. Education and Employment: Educational background and employment status - include when vocational support is needed

6. Substance Use History: Details of current or past substance use - include when addiction support is identified as a need

Suggested Schedules

1. Risk Assessment Form: Detailed risk assessment template for identifying and managing potential risks

2. Consent Forms: Specific consent forms for information sharing with different agencies and service providers

3. Cultural Support Plan: Detailed plan for ensuring culturally appropriate service delivery

4. Service Directory: List of available support services and contact information

5. Crisis Response Plan: Template for emergency response procedures and contact protocols

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant legal definitions
Intake Assessment
Case Management
Service Provider
Client
Personal Information
Health Information
Support Services
Care Plan
Cultural Support
Emergency Contact
Informed Consent
Privacy Notice
Risk Assessment
Treatment Provider
Next of Kin
Authorized Representative
Healthcare Services
Referral Source
Support Network
Whānau
Primary Care Provider
Cultural Considerations
Service Agreement
Disability Support Services
Mental Health Services
Confidentiality
Information Sharing
Crisis Response
Assessment Period
Service Coordination
Clauses
Personal Information Collection
Privacy and Confidentiality
Consent to Information Sharing
Cultural Considerations
Health Information Collection
Emergency Contact Authorization
Service Coordination
Risk Assessment
Client Rights and Responsibilities
Information Use and Disclosure
Data Storage and Protection
Healthcare Provider Details
Support Services Authorization
Cultural Safety
Mental Health Assessment
Financial Information
Service Delivery Consent
Medical History
Disability Support Requirements
Crisis Management
Information Access Rights
Communication Preferences
Documentation Requirements
Service Provider Obligations
Complaint Process
Relevant Industries

Healthcare

Social Services

Mental Health

Disability Support

Community Services

Aged Care

Youth Services

Rehabilitation Services

Indigenous Health Services

Primary Healthcare

Relevant Teams

Case Management

Intake and Assessment

Clinical Services

Social Services

Client Support

Cultural Services

Quality Assurance

Healthcare Administration

Service Coordination

Risk Management

Relevant Roles

Case Manager

Social Worker

Healthcare Coordinator

Intake Specialist

Clinical Assessment Officer

Service Coordinator

Cultural Support Coordinator

Mental Health Professional

Disability Support Coordinator

Client Services Manager

Healthcare Administrator

Clinical Team Leader

Industries
Privacy Act 2020: Governs how personal information is collected, used, stored, and disclosed. Essential for ensuring proper handling of client data in the intake form.
Health Information Privacy Code 2020: Specific rules for handling health information, including collection, storage, and sharing of health-related data in healthcare settings.
Human Rights Act 1993: Ensures the intake form doesn't discriminate against individuals based on protected characteristics and promotes equal access to services.
New Zealand Public Health and Disability Act 2000: Provides framework for public health services and disability support services, relevant for case management service provision.
Health and Disability Commissioner Act 1994: Protects rights of health and disability services consumers, including right to proper standards of care and informed consent.
Mental Health (Compulsory Assessment and Treatment) Act 1992: Relevant if case management involves mental health services, defining rights and procedures for mental health treatment.
Social Security Act 2018: May be relevant for case management involving social services and support entitlements.
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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