Full Circle Youth and Family Services is collecting intake information for a new client, including their name, date of birth, gender, ethnicity, address, phone numbers, emergency contacts, referral source, presenting problems, requested services, payment source, previous providers, and risks. The client's biological parents may also be referred for services. This intake sheet gathers essential identifying and clinical information to facilitate the client's screening and intake process.

1. Full Circle Youth and Family Services, PLLC
Screening/Intake Information Sheet
Please fax referral to 405-455-7292
Date:
Client Name:
SSN:
D.O.B.
Gender:
Age:
Culture/Ethnicity:
Address:
City:
State:
Zip:
Biological Parent(s) Name:
Phone #:
*Will biological parent(s) be referred for services to Full Circle*?
Y
N
Foster Parent(s) Name:
Home Phone:
Work Phone:
School: ______________ Judge: ___________ JD#______________ KK#__________
Emergency Contact Information:
Name:
Contact Phone:
Referral Source:
Caseworker/Probation Officer:
Phone#:___
Presenting Problems:
Services Requesting:
Responsible Fee / Pay Source:
ID Number:
Previous Mental Health Providers:
Suicidal/Homicidal Risks/Aggressive Behaviors?
For staff use only
Intake Scheduled?
Y
N
Intake Date & Time: