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?

 


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.

Insurance Company:

Insurance Co. Phone Number:

Insurance ID #:

Insurance Group #:

Policy Holder Name:

Policy Holder’s Social Security #:

Policy Holder’s DOB:


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:


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:

Oregon Community Programs https://www.oregoncommunityprograms.org
Signature Certificate
Document name: New Youth Information Sheet
Unique Document ID: ce254a2022c066fc5497d29b3d37c7fb8e136464
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