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

Name of Youth:   Date of Birth:

Biological mother:   Step-mother:

Biological father:    Step-father:

Adoptive/foster parents:

Is there a legal parenting plan or custody agreement in place? YesNo

If yes, please note: CFD requires a copy of the legal documentation of parenting or custody agreement in order to provide services. The legal guardian must be present to consent to services.

Is custody being contested? YesNo

If yes, please describe:

Describe any conflict in family relationships that impact the child:

Significant others involved in the child’s life:

If your child has ever been sexually, physically, or emotionally/verbally abused, please describe:

Has your child ever:  Been cruel to animals Set fires

Has your child ever witnessed domestic violence? YesNo

Has your child ever experienced the loss or death of a significant family member? YesNo

Does your child have difficulty making or keeping friends? YesNo

Does your child currently express thoughts of harming him/herself or others? YesNo

          If so, how likely is your child to act on these thoughts? UnlikelyLikely

Has he/she had thoughts of harming him/herself or others in the past? YesNo

Has your child or anyone in your family ever received counseling? YesNo

Has anyone in the family threatened or attempted suicide? YesNo

Has a family member’s drug or alcohol use caused problems in the family? YesNo

Has your child, or any family member, had legal problems? YesNo

Grades received: HighAverageLow

In school, the child has:  No behavioral problems Some behavioral problems Frequent behavioral problems Learning disability Individualized Education Plan (IEP)