ARP-DUII Data Packet


**Please complete this form for the person who is receiving services**

Legal Name: Last Name at Birth: Preferred Name: Date of Birth:  

Name of person completing form (if other than individual):  

Name and relationship of referral source:

If other, please explain:  

Physical Address: City, State, Zip: Mailing Address (if different): City, State, Zip:  Okay to send mail?

 

Contact Phone Numbers: 

Primary phone number: Phone Type:

Number belongs to: Okay to leave a message?
If someone else answers, is it okay to identify as CFD and leave a detailed message with them?
 

Alternate phone number: Phone Type:

Number belongs to: Okay to leave a message?
If someone else answers, is it okay to identify as CFD and leave a detailed message with them?

Email address:  

How would you like to receive appointment confirmations?

Send confirmations to: 
 

* By marking yes to receive appointment confirmations by text or email in the box above, I request that confirmation of my appointments be done by text message or email. I understand I will not receive confirmation by telephone calls. If my text message number or email address changes, I will notify CFD. I am aware that information contained in text messages and emails cannot always be guaranteed to remain confidential due to the limitations of electronic media.

How would you like to receive documents that your therapist may want to send to you (resource information, forms, handouts, etc.)? Please only choose one; you may contact CFD should your preferences change. 

Gender as Specified on Insurance:

Gender Self-Identification, if different:
If other, please describe:

Pronouns:

If other, please describe:  

 

Insurance Provider:

Insurance Co. Name:

Primary insurance ID number:

Primary insurance Group number:  

Do you have secondary insurance?

Insurance Co. Name:

Secondary insurance ID number:

Secondary insurance Group number:

 

Race:

 Ethnicity:

 

Living Status:

Tribal Member:

Tribe Name:  

Marital Status:

 

Tobacco Use: 

If yes, which type:
 

Smoking Status: 

Preferred Language:

Is a translator needed?

 

Military Status: Are you currently serving in the military?

Legal Issues:

Arrest History: 

Number of Arrests in Past Month: Total Arrests:

Number of DUII Arrests in Past Month: Total DUII Arrests:

Substance Use in Last 90 Days:

 

Employment Status:

Education:

Highest Grade Completed:

Household Income:

Estimated gross household yearly income: $

Number of people supported by household income (include self):

Number of child dependents (Ages 0-17 supported by household income):  

Principle Income Source: 

Emergency Contact Information:

Name: Relationship: Address:

Phone number:  

Medical Information:

Primary Care Physician's Name (PCP):

Phone: Fax:

When was the last time you saw your PCP?  

 

Dentist's Name: Phone: Fax:  

 

Psychiatric/Psychiatric Nurse Practitioner Name:

Phone: Fax:  

 

Are you pregnant?

If pregnant, are you receiving prenatal care?
If yes, who is your prenatal healthcare provider?

Phone: Fax:  

 

**DUII Clients Only** Oregon Driver's License or I.D. # if no license:  

 

Please list any concerns you are having at this time:

Some people experience things that make life more difficult. Please check those things listed below that you are concerned about:

What do you hope to get from services at CFD?

 

 

Disclaimer regarding Couples Therapy:

Oregon Health Plan does not cover couples therapy. CFD provides family therapy, which can involve members of a couple. CFD will open a file and bill insurance for an identified person, who is known as the client. Anyone other than the client involved in services is known as an additional participant. The additional participant does not have the legal rights that a client has, such as access to client records.

Are any family members currently receiving services at CFD?

Do you have a close friend or family member who works at CFD?
 

 

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things:

Feeling down, depressed or hopeless:

Trouble falling asleep, staying asleep or sleeping too much:

Feeling tired or having little energy:

Poor appetite or overeating:

Feeling bad about yourself, or that you are a failure or have let yourself or your family down:

Trouble concentrating on things such as reading or watching television:

Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:

Thoughts of that you would be better off dead, or of hurting yourself in some way:

          If so, how likely are you to act on these thoughts?

If you checked off any problems from this list, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious or on edge:

Not being able to stop or control worrying:

Worrying too much about different things:

Trouble relaxing:

Being so restless that it is hard to sit still:

Becoming easily annoyed or irritable:

Feeling afraid as if something awful might happen:

If you checked off any problems from this list, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

 

Infectious Disease Risk Assessment

**The following questions are necessary to assess your risk for infectious diseases. Please answer these questions. Confidentiality laws protect all answers.**

Infectious Disease Risk

Have you seen a health care provider in the past three months?

Do you or have you lived on the street or in a shelter?

Have you ever been in jail/prison/juvenile detention?

Have you ever been in a long-term care facility (mental health hospital, nursing home, rehab)?

In the past 3 months, have you traveled outside the US?

If yes, where?

Are you a combat veteran?

In the past year, have you had a tattoo, body piercing, acupuncture, or contact with blood?

Where were you born?

How long have you been in the US?

Have you lived with anyone diagnosed with TB in the past year?

Have you ever been treated for TB?

Have you ever been told you have Hepatitis A?

Have you ever been told you have Hepatitis B?

Have you ever been told you have Hepatitis C?

Have you ever used needles to shoot drugs?

Have you ever shared needles or syringes to inject drugs?

Have you ever had a job where you were at risk for needle sticks or blood contact?

In the past year, have you or anyone you had sex with had an STD or Hepatitis?

In the past 30 days, have you had any of these symptoms lasting more than 2 weeks?

Nausea:

Fever:

Drenching night sweats that were so bad you had to change clothes or bed sheets:

Productive cough:

Coughing up blood:

Shortness of breath:

Lumps or swollen glands in the neck or armpits:

Loss of weight without trying:

Diarrhea lasting more than a week:

Brown tinged urine:

Extreme fatigue:

Jaundice or yellow eyes:

Missed periods for last two months:

HIV/AIDS/Hepatitis C Risk

Did you receive a blood transfusion before 1992?

Have you received blood products produced before 1987 for clotting problems?

Was your birth mother infected by Hepatitis C during the time of your birth?

Have you been or are you currently on long-term kidney dialysis?

Have you had unprotected sex with someone who has the blood disease hemophilia?

Have you had unprotected sex with a person who injects drugs?

Have you had unprotected sex with a man who has sex with other men?

Have you had sex in exchange for money or drugs in order to survive?

Have you had unprotected sex with more than one partner in the past 6 months?

Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +?

Have you ever injected drugs, even once?

Have you ever been pricked by a needle that may have been infected with HIV or Hep C?

Have you ever had a test for HIV?

If yes, was it within the last six months?

If no, would you like to be tested?

Have you ever had a blood test for Hepatitis C?

If yes, was it within the last six months?

If no, would you like to be tested?

How would you judge your own risk for being infected with HIV? (Please check one)

How would you judge your own risk for being infected with Hepatitis C? (Please check one)

 

Leave this empty:

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