MH Program Data Packet


Center for Family Development

1258 High Street, Eugene, OR 97401 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:


Leave this empty:

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Document name: MH Program Data Packet
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April 16, 2020 11:11 am PSTMH Program Data Packet Uploaded by Jason Dooley - jdooley@c-f-d.org IP 173.8.200.225
April 29, 2020 8:40 am PSTRecords Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
April 29, 2020 9:38 am PSTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
May 5, 2020 9:32 am PSTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225