Oregon Community Programs

New Youth Information Sheet


To be completed by Parent/Guardian prior to or during initial session.


YOUTH

Youth’s Name:

Youth Age: Youth DOB

Sex at Birth:  Gender Identity:

Youth’s Phone Number:


OHP

Youth OHP ID#:

Which CCO is youth assigned to:

Has youth received behavioral health services with any other provider in the last year?

If yes, is the youth currently receiving services with another provider?


BIOLOGICAL FAMILY

Youth’s Parent:

Address:

Phone Number:

Email Address:

 

Youth’s Parent:

Address:

Phone Number:

Email Address:


FOSTER FAMILY

Youth’s Foster Parents:

Address:

Phone Number:

Email Address:


GUARDIAN

Youth’s Legal Guardian:

Address:

Phone Number:

Email Address:


EMERGENCY CONTACT

Emergency Contact Name:

Address:

Phone Number:


CASE WORKER  

Case Worker Name:

Agency:

Phone Number:

Email Address:


SCHOOL  

School Name:

School Phone Number:

Teacher Name:

Current Grade:


PRIVATE INSURANCE

Does youth have private insurance?

OCP is required to bill private insurance prior to billing OHP. An intake coordinator will need a copy of your insurance card. Not applicable? Please mark field with NA.

Insurance Company:

Insurance Co. Phone Number:

Insurance ID #:

Insurance Group #:

Policy Holder Name:

Policy Holder’s Social Security #:

Policy Holder’s DOB:


PRIMARY CARE  

Primary Care Provider (PCP):

Address:

Phone Number:


MEDICAL PROVIDER  

Emergency Medical Provider:

Address:

Phone Number:


DENTAL PROVIDER

Dental Provider Name:

Address:

Phone Number:


 

(Parent/Guardian Phone Number)

 

(Date)

 

Leave this empty:

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Signature Certificate
Document name: New Youth Information Sheet
lock iconUnique Document ID: 0e89e695e588368f1dfb219e855dccfa7245fe88
Timestamp Audit
March 24, 2020 1:47 pm PDTNew Youth Information Sheet Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
March 25, 2020 2:03 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 25, 2020 5:00 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 10:07 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:19 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:35 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 6, 2020 1:58 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 6, 2020 1:58 pm PDTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:08 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:08 am PDTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:51 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 10:51 am PDTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:00 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:00 am PDTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:01 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 8, 2020 11:01 am PDTIntake Coordinator - erikaf@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 13, 2020 11:33 am PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
April 13, 2020 11:34 am PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 16, 2020 10:45 am PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 16, 2020 11:01 am PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 16, 2020 11:13 am PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
June 16, 2020 11:16 am PDTIntake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85