Intake Form Step 1 of 14 7% 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 PlacementName(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 No History of Trauma(Required) Yes No History of Neglect(Required) Yes No History of Violence(Required) Yes No 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 No History of Trauma(Required) Yes No History of Neglect(Required) Yes No History of Violence(Required) Yes No 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? SCHOOLPresent 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 No 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 No Past diagnosis of a learning disorder?(Required) Yes No If Yes – Please explain:(Required) EMPLOYMENTContact Name(Required) Phone Number(Required)Length of time in employment(Required) How is your attendance at work ?(Required) HEALTHIs there a past history of physical illness?(Required) Yes No If Yes - Please explain(Required)Are there any present developmental delays, handicaps or health problems?(Required) Yes No If Yes – Please explainWhen 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 No 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 No Any history of depression?(Required) Yes No Any history of self-harming thoughts?(Required) Yes No Any history of self-harming behaviour?(Required) Yes No 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 No 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 No Low self-esteem(Required) Yes No Pregnancy(Required) Yes No Developmental delays.(Required) Yes No Aggressive behavior(Required) Yes No Eating problems.(Required) Yes No Conflict with parents(Required) Yes No Prostitution(Required) Yes No Sleeping problems.(Required) Yes No Problems with anger.(Required) Yes No Running away(Required) Yes No Neglect(Required) Yes No Trauma(Required) Yes No Physical abuse(Required) Yes No Sexual abuse(Required) Yes No Grief issues.(Required) Yes No Self-mutilation(Required) Yes No Attention deficit concerns(Required) Yes No Bullying(Required) Yes No Being Bullied(Required) Yes No 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 No Does the youth have a lot of friends?(Required) Yes No Does the youth argue with peers?(Required) Yes No Does the youth have any close friends?(Required) Yes No Does the youth get into fights easily?(Required) Yes No Does the youth hang out with friends who get into trouble?(Required) Yes No Has the youth engaged in sexual activity?(Required) Yes No Is the youth in need of social supports?(Required) Yes No CULTURAL:Is the youth aware of his/her cultural heritage?(Required) Yes No Does the youth participate in cultural activities?(Required) Yes No Does the youth’s family practice their cultural beliefs?(Required) Yes No Are there any specific restrictions about cultural teachings the program should be aware of?(Required) Yes No If Yes – Please explain: LEGAL:Does the youth have a history of legal charges or arrests?(Required) Yes No If Yes – Please list:(Required) Is there any present involvement with the police or legal system?(Required) Yes No If Yes – Please explain:(Required)Probation Order:(Required) Yes No 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 No 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 No 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 No Does the youth E-smoke/Vapor?(Required) Yes No 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 No Risk taking behaviors(Required) Yes No Do members of the youth’s family abuse substances?(Required) Yes No If Yes – Please list who does: Family Member . 1 2 3 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)
