CHAT Therapeutic Counseling Intake Form

Glenn County Health & Human Services Agency

**Incomplete Forms Will Be Returned**

Counseling Intake forms can be mailed to GCHHSA- CHAT Program 420 E Laurel St, Willows CA 95988 or faxed to (530) 934-6499

If you have any questions please call David Prest at 934-1578

CHILD CONTACT INFORMATION
Child’s Last Name: Child’s First Name MI:
Street Address: City/State: Zip:
Home Phone: / ( / - / Emergency Phone: / ( / ) / -
CHILD DEMOGRAPHIC INFORMATION
Date of Birth: / / / / / Gender: Male Female Unknown
Social Security #: / - / - / Medi-Cal #:
Ethnicity / Is the child of Hispanic or Latino origin?
Yes, Hispanic or Latino Origin (if known, check all that apply) Not of Hispanic or Latino Origin Unknown
Mexican-American/Chicano
Latin American
Spanish
Race(Check all that apply) / Caucasian African American American Indian Asian Other (specify)______
Child’s Primary Language(choose one) / English Spanish Lao Hmong Other (specify)______
Funding Agency / CHAT HRA Contract
Private Insurance Victim Witness
Healthy Families Other (specify)______
CHILD HISTORY
Out of Home Placement Yes No Unk Suicidal Yes No Unk Expelled Yes No Unk
Running Away Yes No Unk Learning Disability Yes No Unk
Substance Abuse Yes No Unk Arrested Yes No Unk
Failing One or More Classes Yes No Unk IEP(Individual Education Plan) Yes No Unk
Psychiatric Hospital Yes No Unk Suspended Yes No Unk
CURRENT LIVING SITUATION
Home, living independently Foster Family Home Juvenile Hall PHF/Inpatient Psychiatric Hospital Homeless
Home, living with parent(s) Group Home Level 1-11 Camp/Ranch Children’s Treatment Facility Other
Home, living with relative(s) Group Home Level 12-14 CYA Residential Treatment Center Unknown
Home, living with non-relative(s) Drug & Alcohol Facility SNF/ICF/MD
For children placed out of home, can the child’s contact information be shared with their birth parent(s)? Yes No Not Placed
Birth Mother’s Name: Birth Father’s Name:
CAREGIVER CONTACT INFORMATION
Caregiver’s Last Name: Caregiver’s First Name: MI
Relationship to Child: Caregiver’s Phone Same as Child / ( / ) / -
Primary Language of Caregiver (choose only one): English Spanish Lao Hmong Other (specify) ______
APPOINTMENT CONTACT INFORMATION(if different from Caregiver information)
Contact for Appointments: Contact Phone: / ( / ) / -
REFERRAL INFORMATION
Referring Person: Referral Phone: / ( / ) / -
Referral Agency / Mental Health
Public Health
Drug & Alcohol
Social Services
Probation / Schools
CPS
Community Mental Health Unit (HRA)
Victim Witness
CalWORKS / First Five Commision
Sacramento Valley Family Services
Far Northern Regional
Northern Valley Catholic Social Services
Other (specify) ______
Reason(s) for Referral (i.e. bullying, domestic violence, etc.)
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** FOR HHSA STAFF USE ONLY **
Date Referral was recieved: / /
Glenn County Child Counseling Services
Intake Information
Page 1 of 1 / Date Logged & scanned:
Date family was contacted & services were offered / / / /

CONFIDENTIAL PATIENT INFORMATION (SEE CALIFORNIA WELFARE AND INSTITUTIONS CODE SECTION § 5328)

Child Counseling Action Form

Date:______

Name of Client(s):______

Date Referral Received:______

Initial Intake Date:______

Funding Source For Services

CHAT: _____

Medi-Cal: _____

Other: _____

Counseling Sessions:

Weekly:______

Bi-Weekly:______

Monthly:______

As Needed:______

Comments:

______

Referring Person for Counseling:______

GCHHSA Therapeutic Counseling Intake Form Revised 12/17/13dp