First name: * Last name: * Gender: FemaleMaleNon-Binary/Third Gender Birthdate - Must use format MM/DD/YYYY: * Race: African AmericanAlaskan NativeAsianBlackCaucasianLatinoMiddle EasternMultiracialNative American/American IndianOtherPacific IslanderWhite The client speaks englishFamily Backbround Parent/Guardian Name: Parent/Guardian Relationship: Parent/Guardian Email: Parent/Guardian Phone: Street: City: State: ZIP: What is the primary language spoken in the home?: Describe Behavior at Home: Are there any other details about the youth's family you can share?: Income: Health Information List any current medical problems: List any medications: List Mental Health Diagnoses: Does client have medicaid?Risk Factors has failed a grade-level has failed a class/course is experiencing anxiety/depression/mental health issues is truant from school is gang affiliated is gang involved is sexually active has excessive dependence on her parents has experienced neglectful or poor parenting has runaway from home (at some point displays aggressive behaviors has poor social skills has behavior problems at school has attempted suicide or has suicidal ideations has been physically/mentally/sexually abused has experienced human trafficking/child porn/prostitution has a history of fire setting Has been/is involved in the juvenile justice system has a history of self harm/mutilation current/past substance use has poor peer associations is withdrawn is/has been involved with CPS impulsive/risk taking parent/sibling convicted of a crime School Information: Current Grade Level: School : Describe Behavior at School: How many times has this youth been expelled from school?: How many long-term suspensions has this student received?: How many times has she been suspended from school?: How many school days was this student absent from school LAST school year): How many school days has this student been absent from school (this year): This student has an Individualized Education PlanReferral Source Referral Name: Referring Organization: Referral Phone: Referral Email: Support Systems What kind of support systems does this youth have in place?: What other community programs is this youth involved?: Please provide the youth's therapist name & contact info if possible: Does adolescent have reliable transportation to and from program?: For office use only: List 3 reasons you are referring your child Reason for Referring #1: Reason for Referring #2: Reason for Referring #3: * These fields are required.