Intake Form

Step 1 of 14

Name of Youth:(Required)

Preferred Name:(Required)

Gender:(Required)

Male

Female

Date(Required)

Month

Day

Year

Gender Identification/Sexual Orientation:(Required)

Height(Required)

Weight(Required)

Hair Color(Required)

Eye Color(Required)

Hair Length(Required)

Allergies(Required)

Home Community:(Required)

Band(Required)

Spiritual Belief:(Required)

Ethnicity:(Required)

Treaty Number:(Required)

Health Care Number:(Required)

School(Required)

Grade(Required)

Youth Cell Number:(Required)

Referral Source:(Required)

Fax

Phone Office(Required)

Cell(Required)

Email(Required)

Social Worker:(Required)

Status of Youth:(Required)

TGO

PGO

Other

Emergency Procedure /AWOL on call number:

Cell(Required)

Low

Med

High

Presenting Issues:(Required)

Urgent Needs (including suicide and violent risk):(Required)

Special Needs/accommodations:(Required)

Degree of family support for youth:(Required)

Low

Med

High

Current Placement

Name(Required)

Address(Required)

Phone Number(Required)

Length of Stay(Required)

Goals Achieved at Placement:(Required)

Reason for leaving:(Required)

FAMILY SYSTEM:

Status of parents: Married(Required)

Cohabitating

Divorced

Separated

Mother(Required)

Phone Number(Required)

Culture(Required)

Ethnicity(Required)

Spiritual Beliefs(Required)

Nature of relationship(Required)

Is she a support to youth(Required)

Contact Restrictions(Required)

Presenting Problems (Needs, abilities, strengths):(Required)

Medical History:(Required)

Behavioral Health History (Mental Health Issues):(Required)

Legal History:(Required)

History of Abuse(Required)

Yes

History of Trauma(Required)

Yes

History of Neglect(Required)

Yes

History of Violence(Required)

Yes

Educational and Employment History:(Required)

Father

Father(Required)

Phone Number(Required)

Culture(Required)

Ethnicity(Required)

Spiritual Beliefs(Required)

Nature of relationship(Required)

Is she a support to youth(Required)

Contact Restrictions(Required)

Presenting Problems (Needs, abilities, strengths):(Required)

Medical History:(Required)

Behavioral Health History (Mental Health Issues):(Required)

Legal History:(Required)

History of Abuse(Required)

Yes

History of Trauma(Required)

Yes

History of Neglect(Required)

Yes

History of Violence(Required)

Yes

Educational and Employment History:(Required)

Siblings (Name, Age, nature of relationship, contact info if appropriate):

Name(Required)

Age(Required)

Relationship(Required)

Name(Required)

Age(Required)

Relationship(Required)

Who has been the primary caregiver?

Both Parents(Required)

Mother

Father

Grandparents

Step-Parent(Required)

Adoptive Parent

Foster Parent

Other

Who is the present caregiver?(Required)

Both Parents

Mother

Father

Grandparents

Step-Parent

Adoptive Parent

Foster Parent

Other

How many caregivers did the youth have during the first five years of his/her life?(Required)

How many caregivers has the youth lived with in total?(Required)

Has the youth reached all his milestones?(Required)

How many times has the youth been relocated geographically since birth?(Required)

Have there been any recent loses in the clients’ life? (Family, friends or pets)(Required)

Yes

No___

If Yes – Who passed away and when?

SCHOOL

Present school's Name(Required)

Contact Name(Required)

Phone Number(Required)

How long?(Required)

Outreach Program or Correspondence Program(Required)

How long?(Required)

Last completed Grade?(Required)

Grades failed?

Yes

If Yes – What grades

Marks obtained at school? Below Average(Required)

Average

above Average

Acting out behaviors at school?(Required)

None

Skipping Classes

Aggressive Behavior

Defiant Attitude

Verbally Aggressive

History of learning difficulties?(Required)

Yes

Past diagnosis of a learning disorder?(Required)

Yes

If Yes – Please explain:(Required)

EMPLOYMENT

Contact Name(Required)

Phone Number(Required)

Length of time in employment(Required)

How is your attendance at work ?(Required)

HEALTH

Is there a past history of physical illness?(Required)

Yes

If Yes - Please explain(Required)

Are there any present developmental delays, handicaps or health problems?(Required)

Yes

If Yes – Please explain

When was youths last?

Medical(Required)

Dental(Required)

Optical(Required)

Name of Physician(Required)

Phone(Required)

Address(Required)

Name of Dentist(Required)

Phone(Required)

Address(Required)

Name of Optometrist(Required)

Phone(Required)

Address(Required)

Any concerns re: vision, speech, hearing, other:(Required)

Current Medication (name, when, amount, how often, efficacy of meds):(Required)

Past Medication (name, when, amount, how often):(Required)

Has the youth received counseling?(Required)

Yes

If Yes Please explain:(Required)

Name of Therapist(Required)

Phone(Required)

Last appointment(Required)

Next Appointment(Required)

Concerns re: fire setting, cruelty to animals, life stress, others:(Required)

Was the youth exposed to pre-natal drinking by mother?(Required)

Yes

Any history of depression?(Required)

Yes

Any history of self-harming thoughts?(Required)

Yes

Any history of self-harming behaviour?(Required)

Yes

If yes – How many times

Date of the most recent: year(Required)

month(Required)

day(Required)

If yes to the above is a Safety Plan in place:(Required)

Yes

Immunization:

When was youth last immunized:(Required)

When is youth do for next immunization(Required)

Self

Has the youth experienced difficulty in any of the following areas?

Poor social skills.(Required)

Yes

Low self-esteem(Required)

Yes

Pregnancy(Required)

Yes

Developmental delays.(Required)

Yes

Aggressive behavior(Required)

Yes

Eating problems.(Required)

Yes

Conflict with parents(Required)

Yes

Prostitution(Required)

Yes

Sleeping problems.(Required)

Yes

Problems with anger.(Required)

Yes

Running away(Required)

Yes

Neglect(Required)

Yes

Trauma(Required)

Yes

Physical abuse(Required)

Yes

Sexual abuse(Required)

Yes

Grief issues.(Required)

Yes

Self-mutilation(Required)

Yes

Attention deficit concerns(Required)

Yes

Bullying(Required)

Yes

Being Bullied(Required)

Yes

SOCIAL/LEISURE:

What sporting activities does the youth enjoy?(Required)

What hobbies does the youth engage in?(Required)

What food likes and dislikes does the youth have:(Required)

Does the youth develop friendships easily?(Required)

Yes

Does the youth have a lot of friends?(Required)

Yes

Does the youth argue with peers?(Required)

Yes

Does the youth have any close friends?(Required)

Yes

Does the youth get into fights easily?(Required)

Yes

Does the youth hang out with friends who get into trouble?(Required)

Yes

Has the youth engaged in sexual activity?(Required)

Yes

Is the youth in need of social supports?(Required)

Yes

CULTURAL:

Is the youth aware of his/her cultural heritage?(Required)

Yes

Does the youth participate in cultural activities?(Required)

Yes

Does the youth’s family practice their cultural beliefs?(Required)

Yes

Are there any specific restrictions about cultural teachings the program should be aware of?(Required)

Yes

If Yes – Please explain:

LEGAL:

Does the youth have a history of legal charges or arrests?(Required)

Yes

If Yes – Please list:(Required)

Is there any present involvement with the police or legal system?(Required)

Yes

If Yes – Please explain:(Required)

Probation Order:(Required)

Yes

If Yes - What are the conditions:(Required)

Probation Officer(Required)

Phone(Required)

Does the youth have any legal charges against them at the present time?(Required)

Yes

If Yes – Please list:

Next Court Date

At what age did the youth start demonstrate delinquent behavior? Age(Required)

Is the youth prone to peer pressure?(Required)

Yes

DRUGS, ALCOHOL AND TABACCO: :

How many times has the youth used drugs?(Required)

Never

1-2

3-5

6-9

10-19

20 +

How many times has the youth used alcohol?(Required)

Never

1-2

3-5

6-9

10-19

20 +

Does the youth smoke?(Required)

Yes

Does the youth E-smoke/Vapor?(Required)

Yes

How often does the youth abuse substances? :

Daily(Required)

Weekends(Required)

Minimal(Required)

Times/Month(Required)

Which of the following would you classify the youth with regards to their substance use?(Required)

Experimenter

Has a Substance Problem

Substance Dependent

Type of substance used:(Required)

Intravenous drug use(Required)

Yes

Risk taking behaviors(Required)

Yes

Do members of the youth’s family abuse substances?(Required)

Yes

If Yes – Please list who does: Family Member . 1

Youth has the following documents:

Government Picture ID
I.N. Card
Birth Certificate
Alberta Health Care Card
Treatment Service Card
Treaty Number or Card
Bank Account

When was the last time youths clothing needs were updated:(Required)

Any other comment:(Required)

Intake Form

Intake Form

Emergency Procedure /AWOL on call number:

Current Placement

FAMILY SYSTEM:

Father

Siblings (Name, Age, nature of relationship, contact info if appropriate):

Who has been the primary caregiver?

SCHOOL

EMPLOYMENT

HEALTH

When was youths last?

Immunization:

Self

SOCIAL/LEISURE:

CULTURAL:

LEGAL:

DRUGS, ALCOHOL AND TABACCO: :

How often does the youth abuse substances? :

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