Basic Center Initial Contact QuestionnaireClient/Family InformationYouth's Name *(first and last)Youth's Date of Birth *Youth's Home Address *Parent/Legal Guardian's Name *Parent/Legal Guardian's Phone Number *(xxx) xxx-xxxxWho is completing this form? *- Select -How did you hear about our program? *Presenting ProblemPresenting Circumstances: *(lack of resources, current behavioral or mental health issues, etc.)Are you currently involved with the Department of Health and Human Services or Juvenile Probation? *YesNoHave you ever received services from CEDARS before? *YesNoAre you available to meet for at least two hours weekly, Monday-Friday? *YesNoStrengths/IssuesWhat are the youth's resources/support systems? *Who do you consider to be your support system (formal and informal)?Special Concerns/Needs: *Does the youth have any abuse or neglect issues? *(physical or sexual)YesNoDoes the youth have any current or historical issues with running away or threatening to run away? *YesNoAre there any current safety issues? *YesNoWhat are the current safety issues?Pregnant/ParentingIs the youth pregnant or parenting? *YesNoI'm not sureIf the youth is pregnant, what stage of pregnancy are they in?If the youth is parenting, what are the names, ages, and sex of the youth's children?Living ArrangementsWho does the youth currently live with? *EducationWhat is the youth's current educational status? *- Select -What school does the youth attend?Mental and Behavioral HealthDoes the youth have current or historical thoughts of hurting themself or others? *YesNoAre there any other behavioral health concerns or issues that haven't been addressed in this form yet? *YesNoIf yes, what are those concerns?Is the youth currently in therapy? *YesNoIf no, are you interested in individual or family therapy for the youth with our clinician?YesNoSubstance UseDoes the youth have current or historical use of drugs or alcohol? *YesNoLegalDoes the youth have any law violations or warrants? *YesNoList the youth's law violations/warrants:Submit
