Youth & Family Information Step 1

Date:

Date

Youth's Name:

DOB:

Date

Contact Phone #:

Format: (000) 000-0000.

Youth's Gender:

Age:

Youth Address:

Form Completed By:

Relationship to Child:

Youth Health Insurance:

How were you referred to The Link?

Biological Mothers Name:

Age:

Occupation:

Highest Education Level:

Any previous mental health treatment?

If yes, reason for treatment and how long ago?

Any history of substance abuse (alcohol or drugs)?

If yes, please describe:

Biological Fathers Name:

Age:

Occupation:

Highest Education Level:

Any previous mental health treatment?

If yes, reason for treatment & how long ago?

Any history of substance abuse (alcohol or drugs)?

If yes, please describe:

*If applicable, please answer below, if not leave blank*

Stepparent or Guardian Name:

Age:

Occupation:

Highest Education Level:

Any previous mental health treatment?

If yes, reason for treatment & how long ago?

Any history of substance abuse (alcohol or drugs)?

If yes, please describe:

* Use the back of the next page if more space is needed.

Marital Status of Biological or Adoptive Parents:

Who has legal custody?

Primary Physical Custody?

If child is not with natural parents, when and why did this occur?

Is a parent or has a parent ever been incarcerated?

Has a parent or guardian passed away?

How long?

Race (check all that apply):

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Youth & Family Information

FAMILY HISTORY

Marital Status of Biological or Adoptive Parents: