CM-YA Intake Form PROVIDER MENUPROVIDER MENUDashboardNewsLinkseLibrary CM-YA eLibraryCM-EA eLibraryCM-A eLibraryCM-PO eLibraryFavorites Account Change PasswordLogout Provider Name(Required) Agency Name(Required) Agency Client ID(Required) Client Age(Required)Gender(Required) Male Female Other Ethnicity(Required) NOT Hispanic or Latino Hispanic or Latino Primary Race(Required) Black or African-American White Asian American Indian or Alaskan Native Pacific Islander Other Secondary Race - If Biracial Select One Black or African-American White Asian American Indian or Alaskan Native Pacific Islander Other First Session Date(Required) MM slash DD slash YYYY Referral Date(Required) MM slash DD slash YYYY Would this youth have been placed out of home if they were not accepted to participate in this program?(Required) Yes No Primary Referral Source(Required) Probation Parole Social Services / Child Protection Mental Health Substance Abuse Agency Court School Police Family Self Other Risk Factors - Check All That Apply(Required) Poor School Performance Poor School Attendance Substance Use Substance Dependence Other Criminal Behavior Mental Health Condition / Disorder Negative Peers Parent Substance Abuse Parent Mental Health Condition / Disorder Parent Incarceration Family Conflict Low Parental Monitoring / Supervision Low Involvement in Prosocial Activities Primary Substance Used(Required) Alcohol Marijuana or other cannabis product Other Previous Treatment - Check All That Apply(Required) None Individual Therapy Family Therapy Outpatient Drug / Alcohol Treatment Inpatient Drug / Alcohol Treatment Outpatient Psychiatric Inpatient Psychiatric Other Residential Treatment Foster Care Alcoholics Anonymous Narcotics Anonymous Living Arrangement(Required) Both Parents Mother Only Father Only Relative Father / Stepmother Mother / Stepfather Mother / Paramour Father / Paramour Foster Parents Other Legal Guardian Living Independently
