This document is an intake form for FullCircle Youth and Family Services that collects contact and background information on a client. It requests identifying information like name, date of birth, contact details, as well as details on biological parents, foster parents if applicable, emergency contacts, referral source, presenting problems, requested services, and previous mental health treatment. Fields are also included to schedule an intake appointment and note any risks.

1. FullCircle Youth
andFamilyServices,PLLCScreening/IntakeInform
ation Sheet
Pleasefaxreferral to 405-455-7292
Date:
ClientName:
SSN:
D.O.B.
Gender:
Age:
Culture/Ethnicity:
Address:
City:
State:
Zip:
BiologicalParent(s)Name:
Phone#:
*Will biologicalparent(s)bereferred for services to Full Circle*?
Y
NFosterParent
(s)Name:
HomePhone:
Work Phone:
School: ______________Judge: ___________ JD#______________ KK#__________
EmergencyContactInformation:
Name:
ContactPhone:
ReferralSource:
Caseworker/ProbationOfficer:
Phone#:___
PresentingProblems:
ServicesRequesting:
Responsible Fee / PaySource:
ID Number:
PreviousMentalHealth Providers:
Suicidal/HomicidalRisks/AggressiveBehaviors?
For staffuseonly
IntakeScheduled?
Y
N
IntakeDate & Time: