Brief Youth Data Packet


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

Legal Name: Last Name at Birth: Preferred/Asserted 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 like to receive documents from the agency?

Please choose only one; you may contact CFD should your preference change.

 

Gender as Specified on Insurance:

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

Pronouns:

If other, please describe:  

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:  

 

In the last year, have you utilized other social service agencies? (e.g., DHS Child Welfare, Self Sufficiency, Social Security)

If yes, where? Name of caseworker, if applicable:  

In the last year, have you accessed other behavioral health (mental health or recovery) provider agencies like Center for Family Development?

If yes, where?  

 

Parent or Guardian: Please complete the information below

Children and parents often experience emotional and/or behavioral difficulties during and following family separation, divorce, or other family conflict. Our goal is to help children and families find solutions so they can carry on with their lives in a productive manner. Please let your therapist know if your family is dealing with the impact of any conflict, separation, divorce, or a change in custody or visitation. CFD will not attempt to gather information to help one parent “win” custody or visitation. Please note:

  • CFD does not provide custody evaluations or make recommendations for custody or visitation.
  • CFD staff and therapists will not voluntarily testify in court related to recommendations for custody or visitation.
  • Biological parents who retain parental rights have a legal right to participate in therapy, regardless of who has custody, until the child turns 18, and have a legal right to clinical records of minors age 13 or younger.
  • CFD therapists will work to include all parental figures in therapy unless involvement creates a potential or real safety risk for the child and/or family members.

Name of adult(s) legally authorized (legal guardian) to consent for services: 

Biological parent(s):

Stepparent(s):

Adoptive/foster parent(s):

Significant others involved in the child's life:

With whom does the youth live?

Is there a legal parenting plan or custody agreement in place?

 

If yes, CFD requires a copy of the legal documentation of parenting or custody agreement in order to provide services. The legal guardian must be present to consent to services.

Is custody being contested?

 If yes, please describe:

 

Has the court terminated anyone's parental rights?

 If yes, full name(s):

 

Leave this empty:

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Document name: Brief Youth Data Packet
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September 24, 2024 1:18 pm PDTBrief Youth Data Packet Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.1
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