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INTAKE FORM
ABOUT US
WHO WE SERVE
PROGRAMS
MOTHER IN ME
STANDING FATHERS
AREAS OF FOCUS
DOMESTIC VIOLENCE
SUBSTANCE ABUSE
PREGNANCY PREVENTION
SEX TRAFFICKING AWARENESS
SUICIDE PREVENTION
EDUCATIONAL SUPPORT
ANTI-BULLYING SUPPORT
LIFE SKILLS SUPPORT
GIVE BACK
VOLUNTEER
DONATE GOODS
DONATE FINANCIALLY
PARTNERS
CURRENT PARTNERS
PARTNERSHIP REQUESTS
WORKSHOPS
EVENTS
CONTACT US
DONATE
First name
*
Last name
*
Birthday
*
Month
Day
Year
Email
Phone
Address
Gender Identify
Preferred Pronouns
Preferred Contact Method
Call
Text
Email
AHCCCS ID #:
Managed Care Organization (MCO)
If other is selected list MCO
SMI Designation
Yes
No
Unknown
DDD Enrolled
Yes
No
Assigned Case Manager
Legal Guardian Verified
Yes
No
N/A
Parent/ Guardian Name (If Applicable)
Relationship (to you)
Parent/ Guardian Phone #
Email
Refferal source
Currently Enrolled in school
Yes
No
School Name
Grade
Education concerns
Academic struggles
Truancy
Behavior concerns
Dropped out
GED interest
Education goals
Currently employed
Yes
No
Currently legal involvement
Yes
No
Diagnosis date (if known)
Month
Day
Year
Hospitilization in the past 12 months
Yes
No
Crisis episodes in the past 6 months
Yes
No
Trauma & Life Experiences
Physical abuse history
Sexual abuse history
Domestic violence exposure
Foster care placement
Parental incarceration
Grief/loss
Community violence exposure
Human trafficking risk
None reported
Functional impairment
School fuctioning
Emotional regualtion
Peer relationships
Hygiene/self-care
Home behavior
Legal involvement
Employment readiness
Social skills
Independent living skills
Describe current challenges
Have you ever had thoughts of not wanting to live
Yes
No
Do you currently have these thoughts
Yes
No
If yes
Current intent
Yes
No
Current Plan
Yes
No
Access to means
Yes
No
Last occurence
I understand the nature of the services provided by Teen Time Outreach. I understand my rights, confidentiality protections, and mandatory reporting exceptions. I understand I may withdraw consent at any time
Yes
No
Member Signature
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Parent/Guardian Signature
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Staff Signature
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Submit
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