Youth Intake Form 2024
Name
First Name
Last Name
Submission Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Youth Race
Please Select
Caucasian
Black/African American
American Indian
Hispanic/Latino
Youth Place of Birth
Youth Religion
Parent Name #1
First Name
Last Name
Marital Status
Please Select
Married
Divorced
Widowed
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Name #2
First Name
Last Name
Marital Status
Please Select
Married
Divorced
Widowed
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CMDP Number
PID Number
On Probation?
Yes
No
Probation Officer Name
Medication Ready?
Yes
No
List of Medication Youth Is Taking
Behavior Concerns
Medical Concerns
Vision/Hearing/Dental/Physical
Rows
Excellent
Satisfied
Needs Improvment
Medical Assistance Needed
Vision
Hearing
Dental
Physical
Please Check All That Apply
Piercings
Tattoos
Food Allergies
Seasonal Allergies
Contacts/ Glasses
Any Others Not Listed
Burning or Itching
Previous Surgeries
Substance Drug Abuse
Current Cold/Flu
Currently Under The Influence of Drugs or Alcohol
Sexually Active
Physical Injuries
Asthma
Previous Hospitalization
Medication Allergies
Drinks Alcohol
Bed Bugs
Lice
Venereal Diseases
Communicable Diseases
Cuts or Scratches
Measles or Chicken Pox
Food Allergies
Visible Rash/Redness
Bruises
Abrasions or Lesions
Please Explain all Checked Items Above
CONSENT FOR SPORTS - To Participate In Sports or Strenuous Activities
Please Select
Yes
No
CONSENT FOR MEDICAL TREATMENT - To provide emergency medical of dental care prescribed by a duly licensed physician (MD) or Dentist (DDS). This career may be under whatever conditions are necessary to preserve the lifetime or well-being of my dependent.
Please Select
Yes
No
CONSENT FOR TRANSPORT - I consent the youth to be transported by Better Together Mesa And its component programs using the company vehicles or the stats personal vehicles.
Please Select
Yes
No
YOUTH GRIEVANCE - I agree that the youth and or his parents or legal guardian have the right to file a grievance of dissatisfaction with care, treatment, or other services they receive from Better Together Mesa. I understand that staff shall not discriminate in any way against my youth or anyone who has participated in an investigative process. I acknowledge receipt of the Better Together Mesa Policy and Procedures for youth grievances. I have read the document and staff have answered my questions about its concerns. I understand the documents and agree to its terms and conditions.
Please Select
Yes
No
CREATIVE ARTS - Better Together Mesa uses creative arts as part of our youth building program. I agreed to allow the youth listed above to be exposed to music development, seminars or sessions, video filming sets for teaching directing/producing skills in the film, industry, and photography lessons to teach the basics and advanced concepts of digital photography. Through the teachings of all three creative art methods, I understand that the youth may be recorded with video, audio devices, or photography for the purpose of teaching creative arts. such video and photography may be used within the company for moral building and use on the company website.
Please Select
Yes
No
Case Manager Name
First Name
Last Name
Case Manager Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Office Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
Case Manager Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Case Manager Region
Supervisor Name
First Name
Last Name
Supervisors Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisors Email
example@example.com
Intake Staff Name
First Name
Last Name
Intake Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: