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 Type:

Number belongs to: Okay to leave a message?
Okay to identify we are calling from CFD?

Alternate: Phone Type:

Number belongs to: Okay to leave a message?
Okay to identify we are calling from CFD?

Email address:  

How would you like to receive appointment confirmations?

Send confirmations to: 

* By marking yes to receive appointment confirmations by text or email in the box above, I request that confirmation of my appointments be done by text message or email. I understand I will not receive confirmation by telephone calls. If my text message number or email address changes, I will notify CFD. I am aware that information contained in text messages and emails cannot always be guaranteed to remain confidential due to the limitations of electronic media.

How would you like to receive documents that your therapist may want to send to you (resource information, forms, handouts, etc.)? You may contact CFD should your preferences change. 

Gender as Specified on Insurance:

Gender Self-Identification, if different:
If other, please describe:


If other, please describe:  




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:


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:  

Medical Information:

Primary Care Physician's Name (PCP):

Phone: Fax:

When was the last time you saw your PCP?  


Dentist's Name: Phone: Fax:  


Psychiatric/Psychiatric Nurse Practitioner Name:

Phone: Fax:  


Are you pregnant?

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

Phone: Fax:  


**DUII Clients Only** Oregon Driver's License or I.D. # if no license:  


Please list any concerns you are having at this time:

Some people experience things that make life more difficult. Please check those things listed below that you are concerned about:

What do you hope to get from services at CFD?



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?


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

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): 


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):  


DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

1(A): Substance Use

Please indicate if you've used any of the following substances:


If other, please describe:  


If other, please describe:  


If other, please describe:  


1(B): Withdrawal

Check any of the following that you experienced after you stopped using alcohol or other drugs:

If other, please describe:  

Did this happen in the last year?

If yes, when?  

Are you interested in quitting tobacco or attending a Tobacco Cessation support group?


1(C): Substance Use Problems

  1. Have you or anyone else felt like you should cut down on your drinking or other substance use?
  2. In the last year, how important have alcohol and/or other drugs been in your life?
  3. In the last year, how troubled or bothered have you been by alcohol or other drug problems?
    Please explain:  
  4. Do you think you have an alcohol and/or drug abuse problem?
  5. Have you ever had an alcohol and/or drug abuse problem?
    If yes, when?  

1(D): Gambling

Have you ever felt the need to lie about your gambling?


Have you ever felt the need to bet more and more money?



DIMENSION 2: Biomedical History and Complications

2(A): Personal History

Please check any that apply:

A physical disability:


Appetite problems:




Chest pain or pressure:


Chronic pain:






Eye problems, blurred or worsening vision:


Fainting, dizziness, or light-headed feelings:


Gained or lost 10 lbs. recently:


Hearing problems:


Heart palpitations, irregular or racing heartbeat:


High blood pressure:


Kidney Problems:


Liver problems:


Lung problems:




Other contagious health condition (e.g., lice, scabies):


Problems with memory or concentration:




Seizures or convulsions:


Sexual problems:


Shakiness or trembling:


Significant headaches:




Thyroid problems:


Traumatic brain injury (e.g., concussion, hit in head):


Unexplained bruises or sores that don't heal:




Please list all medications you are currently taking or have taken in the last year, including non-prescription drugs, and the dosage of each, if known:

Are you under a doctor's care at this time?

When did you last see a doctor?  

Have you had a tetanus shot within the past 10 years?


Have you ever injected drugs?

If yes, when was the last time?  

Have you had any blood tests done since you last used?


Have you been incarcerated or in an inpatient substance abuse recovery program since you last used?

If yes, please explain:  

2(B): Family Medical and Psychiatric History

List serious medical conditions, past or current, of all close family members:

List mental health concerns for all close family members:


DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

What, if any, mental or emotional problems have you experienced in the past?

What, if any, mental or emotional problems are you currently experiencing?

Have you experienced any type of abuse?


Do you have a history of head trauma?


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?


DIMENSION 4: Readiness to Change

Legal History

Have you ever been, or are you,  involved with the legal system?

If yes, when?  

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

  1. Have you ever been in counseling/treatment? (detox, AOD rehab, outpatient mental health)
  2. What, if any, of the following are reasons you use/drink?

If other: please explain:  

DIMENSION 6: Recovery/Living Environment

6(A): Personal Habits and Lifestyle

Work: Hours/Day

Do you enjoy your work?


Do you participate in hobbies?


Exercise (type and how often):  

Amount and Type of caffeine per day:  

Describe any sleep concerns:  

6(B): Spiritual or Religious Beliefs and Practices

What are your religious/spiritual beliefs?  

6(C): Cultural Identification

How do you define yourself culturally?

6(D): Education

  1. Are you currently in school?
    If yes, name of current school:  
  2. School status:
  3. What is your learning style?
  4. Are you required to complete recovery services here in order to stay in school?
  5. Accomplishments (awards, merits, letters, trophies, honor roll, etc.):  
  6. Involvement in extracurricular activities (plays, sports, dances, etc.):  
  7. Has alcohol/drug use affected your school progress?
    If yes, please describe:  

6(E): Supports and Strengths

What drug-free support(s) do you have?

If other, please describe:  

How do you take care of yourself? 

6(F): Self-Help/Support Groups

What self-help groups do you currently attend or have you attended in the past?

If other, please describe:  

Frequency of self-help group attendance in the past 30 days:  

6(G): Family/Living Environment

Members in household:

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

6(H): Strengths

What are your strenghts?


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?



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:

Signature arrow sign here

Signature Certificate
Document name: YRP Data Packet
lock iconUnique Document ID: 57c2f7e6569775edd2ce9c13b5d664d0460f0a08
Timestamp Audit
June 2, 2023 10:53 am PDTYRP Data Packet Uploaded by Do Not Reply - donotreply@c-f-d.org IP
June 2, 2023 10:56 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip:
June 7, 2023 2:13 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip:
June 15, 2023 2:10 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: