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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 DEMOGRAPHICS

Youth's Legal Name:

Chosen Name:

Youth DOB: Youth's Age:

Sex Assigned at Birth: Gender Identity:

Youth's Address:

PARENT 1

(Our records require us to document youth’s biological or adoptive parent(s) information even if youth is not currently residing with that parent.)

Parent Name:

Relation to Youth: Biological ParentAdoptive Parent

Address:

Phone Number:

Email Address:

Residing with Parent: Does youth currently reside with this parent? YesNo

PARENT 2

(Our records require us to document youth’s biological or adoptive parent(s) information even if youth is not currently residing with that parent.)

Parent Name:

Relation to Youth: Biological ParentAdoptive Parent

Address:

Phone Number:

Email Address:

Residing with Parent: Does youth currently reside with this parent? YesNo

ADDITIONAL CAREGIVER(S)

Cargiver Name(s):

Relation to Youth: Foster ParentRelativeOther

If other, please specify:

Address:

Phone Number:

Email Address:

Residing with Caregiver: Does youth currently reside with this caregiver? YesNo

DHS CASE WORKER (If applicable)

Case Worker Name:

Agency/County:

Phone Number:

Email Address:

LEGAL GUARDIAN

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:

Address:

Phone Number:

Email Address:

SCHOOL

School Name:

School Phone Number:

Teacher Name:

Current Grade:

EMERGENCY CONTACT

If the primary caregiver/guardian cannot be reached, whom should OCP call in case of emergency?

Emergency Contact Name:

Relation to Client:

Address:

Phone Number:

PRIMARY CARE PROVIDER (PCP)

Primary Care Provider Name:

Address:

Phone Number:

DENTAL PROVIDER

Dental Provider Name:

Address:

Phone Number:

OTHER PROVIDER (If applicable)

Provider Name:

Provider Specialty:

Address:

Phone Number:

OHP

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

PRIVATE INSURANCE

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 Company:

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

Please Confirm full name and signature.

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Timestamp

Audit

August 2, 2021 1:11 pm PDT

Intake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85

August 2, 2021 1:18 pm PDT

Intake Coordinator - ocpclientpaperwork@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85

August 2, 2021 6:45 pm PDT

New Youth Information Sheet Uploaded by OCP Documents - ocpdocs@oregoncp.org IP 10.0.10.40

September 14, 2022 12:51 pm PDT

OCP Documents - ocpdocs@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.40