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:

YesNo

If yes, reason for treatment and how long ago?

YesNo

If yes, please describe:

Biological Fathers Name:

Age:

Occupation:

Highest Education Level:

YesNo

If yes, reason for treatment & how long ago?

YesNo

If yes, please describe:

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

Stepparent or Guardian Name:

Age:

Occupation:

Highest Education Level:

YesNo

If yes, reason for treatment & how long ago?

YesNo

If yes, please describe:

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

Who has legal custody?

Primary Physical Custody?

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

YesNo

How long?

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Youth & Family Information

FAMILY HISTORY

Marital Status of Biological or Adoptive Parents: