DYS Admin 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):  

How were you referred to CFD?

If other, name and relationship of person who referred:  

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:  

What do you hope to get from services at CFD?

 

 

This section is for YOUTH only. Parent or Guardian: Please complete this form

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 legal access to participate in therapy and request records, regardless of who has custody, until the child turns 18.
  • 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, please note: CFD requires a copy of the legal documentation of parenting or custody agreements in order to provide services. The legal guardian must be present to consent for 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: DYS Admin Data Packet
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June 7, 2023 2:04 pm PSTDYS Admin Data Packet Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.3
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