1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
MH Program 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 client):
Name and relationship of referral source:
Physical Address: City, State, Zip:
Mailing Address (if different): City, State, Zip:
Contact Information
Primary phone number: Number belongs to:
Primary phone type:
OK to leave a message?
OK to identify we are calling from CFD?
Alternate phone number: Number belongs to:
Alternate phone type:
OK to leave a message?
OK to identify we are calling from CFD?
How would you like to receive appointment confirmations?
Send confirmations to:
By marking yes to receive appointment confirmations by text in the box above, I request that confirmation of my appointments be done by text message. I understand I will not receive confirmation by telephone calls. If my text message number changes, I will notify CFD. I am aware that information contained in text messages cannot always be guaranteed to remain confidential due to the limitations of electronic media.
Gender as Specified on Insurance:
Gender Self-Identification, if different:
Preferred pronouns:
Race
Ethnicity
Living Status
Tribal Member:
If yes, enter Tribe Name:
Marital Status:
Tobacco Use:
If yes, which type(s)?
Smoking Status
Language
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 (including 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:
Psychiatrist/Psychiatric Nurse Practitioner Name:
Phone: Fax:
Describe any birth and early childhood complications, medical problems, or developmental delays:
In the last year have you utilized other social service agencies (e.g. DHS Child Welfare, Self Sufficiency, Social Security)?
If yes, where:
In the last year have you accessed other behavioral health provider agencies like Center for Family Development?
If yes, where:
Please list current drug/alcohol and/or gambling services:
Please list previous mental health, drug/alcohol and/or gambling services:
Please list any problems you are having at this time:
Women Only
Are you pregnant?
If pregnant, are you receiving prenatal care?
If yes, who if your prenatal healthcare provider?
Phone: Fax:
