Data Packet Testing


**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 Type:

Number belongs to:

Okay to leave a message?

Okay to identify we are calling from CFD?

Alternate #:

Phone Type:

Number belongs to:

Okay to leave a message?

Okay to identify we are calling from CFD?

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.)? 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:  

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:  

 

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?  

 

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?

 

Personal Habits and Lifestyle:

Work: Hours/Day

Do you enjoy your work?

Comments:  

Do you participate in hobbies?

Comments:  

Exercise (type and how often):  

Amount and Type of caffeine per day:  

Describe any sleep concerns:  

Have you ever been treated for drug/alcohol use?

 Describe any current or past difficulties with drug or alcohol use:  

Are you interested in quitting tobacco or receiving tobacco cessation support?

Have you or anyone else felt like you should cut down on your drinking?

How often do you drink 4 alcoholic drinks in one day?

 

Do you take prescription drugs for non-medical reasons?

 

How often do you use mood altering substances?

 

Gambling:

Have you ever felt the need to lie about your gambling?

Have you ever felt the need to bet more and more money?
 

Family:

Describe the supportive significant others in your life (family, friends, church, professionals, etc.):

Describe your family relationships (family make-up, quality of relationships, marriage or divorce): 

Do you have any safety issues at home?

Comments:  

Spritual or Religious Beliefs and Practices:

What are your religious/spiritual beliefs?  

Cultural Identification:

How do you define yourself culturally?

Strengths:

What are your strengths?

 

Medical History: Please check all that apply:

A physical disability:

 

Appetite problems:

 

Cancer/Tumor:

 

Chest pain or pressure:

 

Chronic pain:

 

Diabetes:

 

Epilepsy:

 

Eye problems, blurred or worsening vision:

 

Fainting, dizziness, or light-headed feelings:

 

Gained or lost 10 lbs. recently:

 

Hearing problems:

 

Heart palpitations, irregular or racing heartbeat:

 

High blood pressure:

 

Kidney Problems:

 

Liver problems:

 

Lung problems:

 

MRSA:

 

Other contagious health condition (e.g., lice, scabies):

 

Problems with memory or concentration:

 

Rheumatism/Arthritis:

 

Seizures or convulsions:

 

Sexual problems:

 

Shakiness or trembling:

 

Significant headaches:

 

Stroke:

 

Thyroid problems:

 

Traumatic brain injury (e.g., concussion, hit in head):

 

Unexplained bruises or sores that don't heal:

 

Other:

 

Please list all medications you are currently taking and the dosage of each, if known:

Describe any birth and early childhood complications, medical problems, or developmental delays:

 

Family Medical and Psychiatric History:

List serious medical conditions, past or current, of all close family members:

List mental health concerns for all close family members:

Leave this empty:

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Document name: Data Packet Testing
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Timestamp Audit
June 20, 2023 3:48 pm PSTData Packet Testing Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.1
June 20, 2023 3:53 pm PSTKrystal Sanders - ksanders@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.8
June 20, 2023 4:02 pm PSTKrystal Sanders - ksanders@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.8
June 20, 2023 4:04 pm PSTKrystal Sanders - ksanders@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.8
June 20, 2023 4:07 pm PSTKrystal Sanders - ksanders@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.8
June 20, 2023 4:10 pm PSTKrystal Sanders - ksanders@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.8
June 20, 2023 4:27 pm PSTKrystal Sanders - ksanders@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.8