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:  

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:  

 

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?

 

 

 

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):  

 

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: MH Child Data Packet
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