Pregnant And Parenting Teens Client Intake Form Lodestar (Branagh Information Group)
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1LODESTAR SERVICE MATRIX FORM: Pregnant and Parenting Teens
Reporting Period: ___ ___
Client ID No. __ __ __ __ __ __ __ __ __
01-Intake
03-Index Child Pregnancy Outcome 0 4-Non-Index Pregnancy Outcome
Client Name _____________________________
##-Month Follow up (Enter age in months of Index Child at follow up.
Use only multiples of 06 (06, 12, 18, 24, etc.)
Case Manager _________________________
Date of Reporting Period ___/___/___
CODES
COUNSELING/HEALTH/MEDICAL
CLIENT
INDEX CH
For each service to the left, Enter
Abuse Victim Counseling
One of the codes below in
Adoption Counseling
BOTH the Client box and the
California Childrens Services (CCS)
Index Child's box, except where
Child Development Intervention
box is darkened.
CPS Intervention
Domestic Violence Intervention
Family Planning
DO NOT LEAVE ANY BOX BLANK.
Medi-Cal
Mental Health Counseling
X - Client/Index Ch refused service
Prenatal Care
0 - Receiving service
Primary Preventive Health Care
1 - Has been referred
Public Health Nurse Home Visits
2 - Referred but did not follow through
Substance Abuse Treatment
3 - Referred but service not accessible
WIC
4 - Needs service but has not yet been
referred.
FINANCIAL/EMPLOYMENT/EDUCATION
CLIENT
INDEX CH
5 - Not referred - service not available
CalWORKs
6 - Not referred - service not needed.
Education
7 - Not eligible for service
Employment
8 - Has completed receiving service
ESL
9 - Unknown
Food Stamps
Head Start
Job/Vocational Counseling or Training
Parenting Education
Special Ed
You may also use the free codes below.
Other Gov. Financial Benefits or Asst.
OTHER SERVICES
CLIENT
INDEX CH
FREE CODES - SERVICE MATRIX
Child Day Care
Document Acquisition
CLIENT INDEX CH
Emergency Food/Shelter/Clothing
Freecode#U
Housing
Freecode#V
Legal Services
Freecode#W
Regional Center
Freecode#X
Transportation
Freecode#Y
Social/Cultural Activities
Freecode#Z
Social Skills Building
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Revised 03/13/98 (ServMtrxPP.xls)
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Parent category: Business