First name: * Last name: * Birthdate - Must use format MM/DD/YYYY: * Gender: FemaleMaleNon-Binary/Third Gender Race: African AmericanAlaskan NativeAsianBlackCaucasianLatinoMiddle EasternMultiracialNative American/American IndianOtherPacific IslanderWhite The client speaks englishFamily Backbround Parent/Guardian Name: Parent/Guardian Email: Parent/Guardian Relationship: Parent/Guardian Phone: Street: City: State: ZIP: What is the primary language spoken in the home?: Are there any other details about the youth's family you can share?: Describe Behavior at Home: 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 involved is gang affiliated has excessive dependence on her parents is sexually active has attempted suicide or has suicidal ideations has behavior problems at school has poor social skills displays aggressive behaviors has runaway from home (at some point has experienced neglectful or poor parenting has been physically/mentally/sexually abused has experienced human trafficking/child porn/prostitution has a history of fire setting has a history of self harm/mutilation Has been/is involved in the juvenile justice system has poor peer associations current/past substance use is withdrawn is/has been involved with CPS parent/sibling convicted of a crime impulsive/risk taking School Information: School : Current Grade Level: Describe Behavior at School: How many times has this youth been expelled from school?: How many times has she been suspended from school?: How many long-term suspensions has this student received?: How many school days has this student been absent from school (this year): How many school days was this student absent from school LAST school 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: * These fields are required.