New Youth Information Sheet
Completed by parent/caregiver/guardian prior to or during initial session.
Please complete all boxes and indicate unknown or not applicable if needed.
Youth's Legal Name:
Youth DOB: Youth's Age:
Sex Assigned at Birth: Gender Identity:
(Our records require us to document youth’s biological or adoptive parent(s) information even if youth is not currently residing with that parent.)
Relation to Youth: Biological ParentAdoptive Parent
Residing with Parent: Does youth currently reside with this parent? YesNo
Relation to Youth: Foster ParentRelativeOther
If other, please specify:
Residing with Caregiver: Does youth currently reside with this caregiver? YesNo
DHS CASE WORKER (If applicable)
Case Worker Name:
Which of the caregivers/CW listed above is the youth's current legal guardian?
If the legal guardian's contact information is not included above, please provide it below.
Legal Guardian Name:
Relation to Youth:
School Phone Number:
If the primary caregiver/guardian cannot be reached, whom should OCP call in case of emergency?
Emergency Contact Name:
Relation to Client:
PRIMARY CARE PROVIDER (PCP)
Primary Care Provider Name:
Dental Provider Name:
OTHER PROVIDER (If applicable)
Youth OHP ID#:
Which CCO is youth assigned to? TrilliumPacificSourceOther
If Other, please specify:
Has youth received behavioral health services with any other provider within the last year? YesNo
If Yes, is the youth currently receiving services with another provider? YesNo
Does the youth have private insurance? YesNo
OCP is required to bill private insurance prior to billing OHP. Reception will need to copy your insurance card.
Insurance Phone Number:
Insurance ID #:
Insurance Group #:
Policy Holder's Name:
Policy Holder's Social Security #:
Policy Holder's DOB:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Youth Information Sheet
Agree & Sign