YRP 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:  

How would you like to receive documents from the agency?

Please choose only one; you may contact CFD should your preference change.

 

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:  

 

Are you pregnant?

If pregnant, are you receiving prenatal care?
If yes, who is your prenatal healthcare provider?

Phone: Fax:  

 

Disclaimer regarding Couples Therapy:

Oregon Health Plan does not cover couples therapy. CFD provides family therapy, which can involve members of a couple. CFD will open a file and bill insurance for an identified person, who is known as the client. Anyone other than the client involved in services is known as an additional participant. The additional participant does not have the legal rights that a client has, such as access to client records.

Are any family members currently receiving services at CFD?

Do you have a close friend or family member who works at CFD?
 

 

The following is about YOUTH only. Parent or Guardian: Please complete the information below.

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 down, depressed or hopeless:

 

Little interest or pleasure in doing things:

 

Trouble falling asleep, staying asleep or sleeping too much:

 

Poor appetite or overeating:

 

Feeling tired or having little energy:

 

Feeling bad about yourself, or that you are a failure or have let yourself or your family down:

 

Trouble concentrating on things such as reading or watching television:

 

Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:

 

Thoughts of that you would be better off dead, or of hurting yourself in some way:

In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

Has there been a time in the past month when you have had serious thoughts about ending your life?

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

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?

 

Have you ever been in counseling for drug/alcohol use issues?

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 ever felt like you should cut down on your drinking or use of other substances?

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?
 

 

Infectious Disease Risk Assessment

**The following questions are necessary to assess your risk for infectious diseases. Please answer these questions. Confidentiality laws protect all answers.**

Infectious Disease Risk

Have you seen a health care provider in the past three months?

Do you or have you lived on the street or in a shelter?

Have you ever been in jail/prison/juvenile detention?

Have you ever been in a long-term care facility (mental health hospital, nursing home, rehab)?

In the past 3 months, have you traveled outside the US?

If yes, where?

Are you a combat veteran?

In the past year, have you had a tattoo, body piercing, acupuncture, or contact with blood?

Where were you born?

How long have you been in the US?

Have you lived with anyone diagnosed with TB in the past year?

Have you ever been treated for TB?

Have you ever been told you have Hepatitis A?

Have you ever been told you have Hepatitis B?

Have you ever been told you have Hepatitis C?

Have you ever used needles to shoot drugs?

Have you ever shared needles or syringes to inject drugs?

Have you ever had a job where you were at risk for needle sticks or blood contact?

In the past year, have you or anyone you had sex with had an STD or Hepatitis?

In the past 30 days, have you had any of these symptoms lasting more than 2 weeks?

Nausea:

Fever:

Drenching night sweats that were so bad you had to change clothes or bed sheets:

Productive cough:

Coughing up blood:

Shortness of breath:

Lumps or swollen glands in the neck or armpits:

Loss of weight without trying:

Diarrhea lasting more than a week:

Brown tinged urine:

Extreme fatigue:

Jaundice or yellow eyes:

Missed periods for last two months:

HIV/AIDS/Hepatitis C Risk

Did you receive a blood transfusion before 1992?

Have you received blood products produced before 1987 for clotting problems?

Was your birth mother infected by Hepatitis C during the time of your birth?

Have you been or are you currently on long-term kidney dialysis?

Have you had unprotected sex with someone who has the blood disease hemophilia?

Have you had unprotected sex with a person who injects drugs?

Have you had unprotected sex with a man who has sex with other men?

Have you had sex in exchange for money or drugs in order to survive?

Have you had unprotected sex with more than one partner in the past 6 months?

Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +?

Have you ever injected drugs, even once?

Have you ever been pricked by a needle that may have been infected with HIV or Hep C?

Have you ever had a test for HIV?

If yes, was it within the last six months?

If no, would you like to be tested?

Have you ever had a blood test for Hepatitis C?

If yes, was it within the last six months?

If no, would you like to be tested?

How would you judge your own risk for being infected with HIV? (Please check one)

How would you judge your own risk for being infected with Hepatitis C? (Please check one)

 

Leave this empty:

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