Oregon Community Programs

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:

  Address:  

Phone Number:  

Email Address:  

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

 


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:

  Address:  

Phone Number:  

Email Address:  

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

 


ADDITIONAL CAREGIVER(S)

Cargiver Name(s):  

Relation to Youth:

If other, please specify:  

Address:  

Phone Number:  

Email Address:  

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

 


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?

 

If Other, please specify:  

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

 

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

 


PRIVATE INSURANCE

Does the youth have private insurance?

 

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:

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Signature Certificate
Document name: New Youth Information Sheet
lock iconUnique Document ID: 2d2cc86a2ca1d5f83f21aef396cc2769ffc6695d
Timestamp Audit
August 2, 2021 1:11 pm PDTIntake 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 PDTIntake 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 PDTNew Youth Information Sheet Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85