Sample Intake Form

The updated TEHCY Follow-Up Intake Form (10/2026) is designed to supplement the Student Residency Questionnaire (SRQ) and support eligibility determinations, service planning, and educational stability discussions. The form helps staff gather clarifying information, identify barriers and needs, document supports and referrals, and facilitate school stability and transportation conversations.

What's new? To help reduce barriers for families and students, the form has been redesigned so that information already collected on the SRQ does not have to be asked again. Instead, the intake process focuses on clarifying responses, addressing unique circumstances, identifying student and family needs, and documenting next steps when additional information is necessary. The form explicitly notes that information already documented on the SRQ should not be re-collected unless clarification is needed.

Why it matters:

• Reduces duplication and minimizes the burden on families.
• Promotes more meaningful conversations focused on student needs rather than repeating questions.
• Supports thorough and consistent eligibility determinations.
• Helps identify educational barriers, stability concerns, and support services.

How to use it:

• Use after reviewing a completed SRQ.
• Focus the conversation on clarification, identified needs, school stability, transportation, and service coordination rather than re-collecting information already provided.
• Pair with the SRQ to create a complete eligibility determination and student support process.

The SRQ tells us what happened. The Follow-Up Intake Form helps us understand what supports the student needs moving forward.