MH Child 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 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:  

 

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:  

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?

 

 

 

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 a legal right to participate in therapy and request records, 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, 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):  

 

 

Have you ever been in counseling for drug/alcohol use issues?

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

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?

 

 

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:

Leave this empty:

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Document name: MH Child Data Packet
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