Youth Information Sheet

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?

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?

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:

Has your child ever witnessed domestic violence?

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

Does your child have difficulty making or keeping friends?

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

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

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

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

Has anyone in the family threatened or attempted suicide?

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

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

Grades received:

In school, the child has:

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Youth Information Sheet
lock iconUnique Document ID: fe9350c0b67ddeeb3c4b72d798a97902108220e3
Timestamp Audit
April 20, 2020 9:10 am PDTYouth Information Sheet Uploaded by Jason Dooley - IP
April 29, 2020 8:25 am PDTRecords Department - added by Jason Dooley - as a CC'd Recipient Ip:
April 29, 2020 9:36 am PDTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip:
March 18, 2021 2:04 pm PDT Document owner has handed over this document to 2021-03-18 14:04:00 -
March 18, 2021 2:04 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: