Family Data Intake Form
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FINGER LAKES PARENT NETWORK, INC.
Family Data Intake Form
Date:
County / Group:
Address:
Phone(s): Home:
City, State, Zip:
Cell:
Email:
Alternate:
☐Self-Referral ☐Agency:
School District:
Referral Source:
Caregiver
Adult Household Members
Relation to
Gender
Race
(Check if
Name (First, MI, Last)
Child/Children
applicable)
☐
☐M ☐F
☐
☐M ☐F
☐
☐M ☐F
☐
☐M ☐F
☐Other _______________
☐
Basic Medicaid
Insurance – Caregiver(s) ONLY
(check all that apply):
☐Medicaid Managed Care
☐No Insurance
1
Child/Youth Name (First, MI, Last)
DOB
Gender
Race
Insurance
☐M ☐F
☐Basic Medicaid
☐Medicaid Managed Care
Systems of Care (SOC) currently serving child (check all that apply):
☐Other
☐OMH ☐Substance Abuse/OASAS ☐OPWDD ☐Special Ed ☐Probation ☐PINS/Diversion
☐No Insurance
☐Juvenile Justice ☐DOH/Early Intervention ☐CPS ☐Preventative ☐Other ________________
School
:
Classification:
Diagnosis
Placement/Location:
Child/Youth Name (First, MI, Last)
DOB
Gender
Race
Insurance
2
☐M ☐F
☐Basic Medicaid
☐Medicaid Managed Care
Systems of Care (SOC) currently serving child (check all that apply):
☐Other
☐OMH ☐Substance Abuse/OASAS ☐OPWDD ☐Special Ed ☐Probation ☐PINS/Diversion
☐No Insurance
☐Juvenile Justice ☐DOH/Early Intervention ☐CPS ☐Preventative ☐Other ________________
School
:
Classification:
Diagnosis
Placement/Location:
3
Child/Youth Name (First, MI, Last)
DOB
Gender
Race
Insurance
☐M ☐F
☐Basic Medicaid
☐Medicaid Managed Care
Systems of Care (SOC) currently serving child (check all that apply):
☐Other
☐OMH ☐Substance Abuse/OASAS ☐OPWDD ☐Special Ed ☐Probation ☐PINS/Diversion
☐No Insurance
☐Juvenile Justice ☐DOH/Early Intervention ☐CPS ☐Preventative ☐Other ________________
School
:
Classification:
Diagnosis
Placement/Location:
Child/Youth Name (First, MI, Last)
DOB
Gender
Race
Insurance
4
☐M ☐F
☐Basic Medicaid
☐Medicaid Managed Care
Systems of Care (SOC) currently serving child (check all that apply):
☐Other
☐OMH ☐Substance Abuse/OASAS ☐OPWDD ☐Special Ed ☐Probation ☐PINS/Diversion
☐No Insurance
☐Juvenile Justice ☐DOH/Early Intervention ☐CPS ☐Preventative ☐Other ________________
School
:
Classification:
Diagnosis
Placement/Location:
☐Check if page 2 needed for additional children/youth.
Annually: Caregiver initial and
date if no changes. Fill out new
Family Peer Advocate
form if changes required
Fax or scan and email to
NO
Signature/Caregiver
Business Office. Maintain
Initials
Date
Changes
Original of all completed intake
☐
forms and keep for 1 year.
☐
Signature /Family Peer Advocate
☐
Business Office
Caregiver
Group Childcare
Scheduler
Teen Facilitator
Waiver Coordinator
Real Scoop Packet
Supervisor
(If applicable)
(If applicable)
DATE SENT
Form 2197
July 2010(Rev. Dec. 2013)(Rev. Nov. 2014)
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