CASE MANAGEMENT CHECKLIST TEMPLATE

Created by ChecklistGuro (https://checklistguro.com)


--- CASE INTAKE & ASSESSMENT ---
[ ] Date of Initial Contact
[ ] Summary of Initial Client Presentation
[ ] Reason for Case Intake (Referral, Self-Referral, Legal Mandate, Other)
[ ] Client Age
[ ] Primary Concerns Reported (Housing, Financial, Legal, Mental Health, Physical Health, Employment, Family/Relationships)
[ ] Referring Agency (if applicable)
[ ] Initial Observations & Potential Risks

--- CLIENT INFORMATION VERIFICATION ---
[ ] Full Name
[ ] Date of Birth (YYYY)
[ ] Address
[ ] Phone Number
[ ] Identification Type (Driver's License, Passport, Social Security Card, Other)
[ ] Copy of Identification
[ ] Emergency Contact Name
[ ] Emergency Contact Phone

--- NEEDS ASSESSMENT & GOAL SETTING ---
[ ] Client's Perceived Needs (in their own words)
[ ] Primary Areas of Need (select all that apply) (Housing, Employment, Healthcare, Financial Assistance, Legal Aid, Education/Training, Mental Health Support, Substance Abuse Support, Transportation)
[ ] Client's Income (monthly)
[ ] Client's Strengths and Resources
[ ] Client's Level of Engagement (Highly Engaged, Moderately Engaged, Low Engagement, Unsure)
[ ] Initial Case Goals (collaboratively established)
[ ] Goal Review Date

--- RESOURCE IDENTIFICATION & ALLOCATION ---
[ ] Primary Support Worker Assigned (Worker A, Worker B, Worker C, Pending Assignment)
[ ] Specialized Services Required (Legal Aid, Mental Health Support, Financial Counseling, Medical Care, Housing Assistance, None)
[ ] Estimated Budget Allocation
[ ] Supporting Documentation (e.g., referrals)
[ ] Referral Date
[ ] Transportation Resources (Agency Provided, Client Responsibility, Pending, Not Required)

--- SERVICE DELIVERY & IMPLEMENTATION ---
[ ] Service Delivery Start Date
[ ] Description of Services Provided
[ ] Number of Sessions Completed
[ ] Service Delivery Method (In-Person, Remote (Video), Remote (Phone))
[ ] Supporting Documentation (e.g., Progress Notes)
[ ] Duration of each session

--- PROGRESS MONITORING & EVALUATION ---
[ ] Date of Progress Review
[ ] Progress Score (1-5)
[ ] Summary of Progress Made
[ ] Challenges Encountered & Solutions Implemented
[ ] Overall Assessment of Progress (On Track, Slightly Behind Schedule, Significantly Behind Schedule, Requires Adjustment)
[ ] Areas Requiring Further Attention (Financial Support, Housing Assistance, Emotional Support, Legal Aid, Healthcare Access)
[ ] Notes from Stakeholder/Client Feedback (if applicable)
[ ] Date of Next Review

--- DOCUMENTATION & RECORD KEEPING ---
[ ] Date of Record Creation
[ ] Summary of Initial Assessment Notes
[ ] Supporting Documentation (e.g., reports, correspondence)
[ ] Record Type (Intake Record, Progress Note, Correspondence, Closure Record)
[ ] Detailed Actions Taken & Outcomes
[ ] Number of Pages in Attached Documents
[ ] Case Manager Signature
[ ] Record Identifier/Case Number

--- COMMUNICATION & COLLABORATION ---
[ ] Last Client Contact Date
[ ] Contact Method (Phone, Email, In-Person)
[ ] Summary of Communication & Key Discussion Points
[ ] Stakeholders Involved in Communication (Client, Family Member, Legal Representative, Service Provider, Case Manager Supervisor)
[ ] Topics Discussed (Progress Updates, Service Plan Review, Financial Matters, Concerns/Challenges, Goals/Objectives)
[ ] Next Communication Planned (Type)
[ ] Date of Next Communication

--- RISK MANAGEMENT & SAFETY ---
[ ] Client’s Current Risk Level (Low, Moderate, High, Critical)
[ ] Description of Identified Risks
[ ] Potential Risk Factors (Select all that apply) (Substance Abuse, Mental Health Concerns, Domestic Violence, Financial Instability, Social Isolation, Neglect/Abuse, Other)
[ ] Safety Plan Details
[ ] Next Safety Plan Review Date
[ ] Location of Potential Safety Concerns
[ ] Staff Signature (Acknowledging Risk Assessment)

--- CASE CLOSURE & TRANSITION ---
[ ] Case Closure Date
[ ] Summary of Case Outcomes & Progress
[ ] Client Satisfaction (Post-Closure) (Very Satisfied, Satisfied, Neutral, Dissatisfied, Very Dissatisfied)
[ ] Recommendations for Future Support (if applicable)
[ ] Referral to Other Services (if applicable) (Yes, No)
[ ] Details of Referral (if applicable)
[ ] Case Manager Signature
[ ] Case Manager Name (Printed)

--- END OF TEMPLATE ---
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