Family Data Intake Form Page 2
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Additional Children/Youth in Household
Child/Youth Name (First, MI, Last)
DOB
Gender
Race
Insurance
5
☐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
6
☐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
7
☐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
8
☐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:
Annually: Caregiver initial and
date if no changes. Fill out new
form if changes required
Signature/Caregiver
NO
Initials
Date
Changes
☐
☐
☐
Signature /Family Peer Advocate
Form 2197
July 2010(Rev. Dec. 2013)(Rev. Nov. 2014)
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