Youth Client Intake Form

Youth Client Intake Form

SHEMA FAMILIA RESOURCES LLC
Youth Information
Youth Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Youth Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School Attendance Status*
School Name
Current Grade
Parent / Guardian Information
Primary Parent/Guardian Full Name*

First NameMiddle InitialLast Name
Relationship to Youth*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address (if different from the youth’s)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Parent/Guardian Full Name

First NameMiddle InitialLast Name
Secondary Guardian Relationship to Youth
Secondary Guardian Contact Notes
Emergency Contacts
Emergency Contact 1 Full Name*

First NameMiddle InitialLast Name
Emergency Contact 1 Relationship*
Emergency Contact 1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Allowed to be Contacted in an Emergency?*

YesNo
Emergency Contact 2 Full Name

First NameMiddle InitialLast Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Allowed to be Contacted in an Emergency?

YesNo
Reason for Referral and Current Concerns
Current concerns*

Behavioral concernsEmotional concernsAcademic concernsSocial concernsFamily concernsSleep concernsAttention or concentration concernsTransitional Life SkillsOther
Please describe the main reason for referral*
Recent changes or stressors
How have these concerns affected daily life?
What would the caregiver or youth like support with?
Services Requested
Requested Services*

Social/Emotional Skills GuidanceParenting/Child mentorEducation Advocacy IEP/504Education small groupsSchool Setting Behavioral AssessmentHome Based Behavioral Assessment
Background Information
Medical history relevant to care

AsthmaDiabetesSeizuresAllergiesOther
Mental & Education History:

AnxietyDepressionADHDTrauma-related concernsBehavioral concernsSelf-HarmAutismIntellectual DisabilityRetained/Held back a grade levelPhysical AggressionVerbal AgressionOppositional/Defiant
Diagnoses and relevant details
Current medications
IEP/504 status
Previous services received
Safety and Risk
In the past few weeks, has the youth had thoughts of hurting themself or ending their life?*

NoYesUnsurePrefer not to say
If yes or unsure, please share any details you feel comfortable providing.
In the past few weeks, has the youth had thoughts of hurting someone else?*

NoYesUnsurePrefer not to say
What safety supports or actions are currently in place?*

Caregiver supervisionTrusted adult supportCounselor or therapist involvedCrisis line or emergency planSafe environment adjustmentsSchool supportMedical care involvedChurch group or mentorProbation OfficerNone currentlyOther
Scheduling Preferences and Availability
Preferred Days*

MondayTuesdayWednesdayThursdayFridaySunday
Preferred Time of Day*

MorningAfternoonEveningAnytime
Scheduling Notes or Constraints
Consent and Agreements
Release of Information
Please share information only with people or organizations you trust to support the youth’s care. You can list up to four contacts below and choose what information may be shared with each one.
Information may be shared only with the individuals and organizations listed in this form for treatment, payment, and healthcare operations. Consent may be revoked in writing at any time, and any disclosure will be limited to the minimum necessary information.
Consent Regarding Release of Information:*

I "AGREE" to give consent to individuals listed belowI "DO NOT" agree to release information to anyone.
Parent/Guardian Signature for Release of Information*
Date*

MonthDayYear
Date
Contact 1
Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Information that may be shared

General progressSchedulingBillingOther
Contact 2
Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Information that may be shared

General progressSchedulingBillingOther
Contact 3
Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Information that may be shared

General progressSchedulingBillingOther
Contact 4
Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Information that may be shared

General progressSchedulingBillingOther
Privacy and Communication Consent*

PhoneEmailText MessageVoicemail
Attendance and Cancellation Agreement*

I agree to provide advance notice for cancellationsI agree to attend scheduled sessions on timeI understand missed appointments may affect service accessOther
Parent / Guardian Signature*
Date*

MonthDayYear
Date
Method of Payment*

Private PaySponsor PayDonor PayInsurance
Service Delivery Method*

In-personOnlineHybridUncertain
Should be Empty:

Youth Client Intake Form

Youth Information

Parent / Guardian Information

Emergency Contacts

Reason for Referral and Current Concerns

Services Requested

Background Information

Safety and Risk

Scheduling Preferences and Availability

Consent and Agreements

Release of Information