MELTZER PEI DIVISION CLIENT ENROLLMENT FORM

PEI DIVISION CLIENT ENROLLMENT FORM
YOUTH AND FAMILY PROGRAMS

Contract ID No.

24555273

Subcontractor

CCD Counseling PA

Workflow

FAYS

Enrollment/Service Start Date

Initials of Staff Assigned to Family

Initials of Intake Staff

PEIRS ENROLLMENT ID NO.

CCD ID NO.

CCD DATA ENTRY

NAME AND DATE

My Therapist/Case Manager is:*
AUTHORIZATION FOR SERVICE
I have been provided information on the referenced Prevention and Early Intervention Program and wish to receive services. I understand that data on my child/youth/family will be collected, maintained, and entered into a secure database. The information will be utilized to track services for evaluation purposes and to ensure quality services are being provided. I hereby authorize my child/youth/family to participate in the program.
Parent Guardian Signature*
Clear
Date*
MonthDayYear
Date
Name of Parent/Guardian*
Name of Index Child/Youth*
CONTRIBUTING FACTORS (Must check at least one and can check all that apply)*
Behavioral ConcernCurrent or Former Military ConnectionCurrent or Past Alcohol Abuse - CaregiverCurrent or Past Alcohol Abuse - YouthCurrent or Past Child Maltreatment or Child Welfare InvolvementCurrent or Past Conflict at SchoolCurrent or Past Criminal Justice Involvement - YouthCurrent or Past Domestic or Interpersonal ViolenceCurrent or Past Use or Abuse of Other Substance - YouthDevelopmental Delay or Disability - CaregiverDevelopmental Delay or Disability - Index Child/YouthFamily Dynamics/Structure ConcernFamily or Household ConflictHigh Stress LevelHomeless/RunawayHousehold has a child with developmental delays or disabilitiesHousehold has a history of alcohol abuse or a need for alcohol abuse treatmentHousehold has a history of substance abuse or needs substance abuse treatmentLow School Attainment - CaregiverLow-Income HouseholdMental Health Concern - CaregiverMental Health Concern - Index Child/YouthParenting Skills ConcernSchool Engagement ConcernSocial Support ConcernHousehold contains an enrollee who is Pregnant and under 21
Current Language Spoken in the Home (Select One):*
Referral Name*
Referral Type*
Estimated Monthly Gross Income*
# Household Members*
Income Source*
Social security/disabilityAlimonyRent from TenantsTANFCash assistance from friends/family or relativesSalary/wagesChild supportUnemployment benefitsOther
Index Child /Youth Information
PEIRS ENROLLMENT ID NO. ________________________________
First Name:*
Middle Name:
Last Name:*
Suffix:
Date of Birth*
Gender:*
MaleFemale
SS#:*
Primary Phone:
Area CodePhone Number
Index Youth Email*
Hispanic Origin:*
HispanicNon-HIspanicUnable to Determine
Race (select all that apply)*
American Indian/ Alaska NativeAsianBlackNative Hawaiian/Pacific IslanderUnable to DetermineDeclined to IndicateWhite
INDEX CHILD/YOUTH - PRIMARY ADDRESS*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Disability Status:*
YesNoNot Assessed
Youth Highest Education Attained:
Less than KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDid Not GraduateGraduated H.S.Received GEDPost HS Technical DegreeCompleted Associate DegreeSome CollegeCollege GraduatePost GraduateNot AssessedOther
Youth Current Living Situation:
I am staying in a public or private facility providing temporary shelter (i.e. shelter, mission, single room facility or motel)I live in my home which I ownI live in my home which I rentI am staying with friends or family members on a temporary basisI live with parents or family membersI live in public housingI live in some other stable arrangementI am incarceratedI am staying on the streets, in a car, park, sidewalk, abandoned building, or any unstable or nonpermanent situationI live in a foster care environmentNot assessed
Is Youth an Expectant Parent:
YesNo
If so, delivery due date:
MonthDayYear
Date
Youth Education Status:
Licensed day careCertified Pre-KElementary schoolMiddle schoolHigh schoolCollegeTech trainingGEDNot EnrolledNot Assessed
Is youth's current living situation a temporary arrangement due to housing loss or economic hardship?
YesNoNot Assessed
Primary Participating Caregiver Information
Person ID NO. ______________________________________
First Name:*
Middle Name:
Last Name:*
Suffix:
Date of Birth*
Gender:*
MaleFemale
Primary Phone:*
Area CodePhone Number
Primary Email:*
example@example.com
Hispanic Origin:*
HispanicNon-HIspanicUnable to Determine
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Race (select all that apply)*
American Indian/ Alaska NativeAsianBlackNative Hawaiian/Pacific IslanderUnable to DetermineDeclined to IndicateWhite
Disability Status:*
YesNoNot Assessed
Primary Language Spoken in the Home (Select One):
Marital Status
Single, Never MarriedNot married, but living together with partnerMarriedSeparatedDivorcedWidowedUnknown
Highest Education Attained:
Less than KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDid Not GraduateGraduated H.S.Received GEDPost HS Technical DegreeCompleted Associate DegreeSome CollegeCollege GraduatePost GraduateNot AssessedOther
Military Status:
No Military ServiceNot IndicatedActive DutyActive ReserveInactive ReserveNational GuardRetiredVeteran (discharge other than dishonorable)Discharged – Dishonorable
Current Living Situation:
I am staying in a public or private facility providing temporary shelter (i.e. shelter, mission, single room facility or motel)I live in my home which I ownI live in my home which I rentI am staying with friends or family members on a temporary basisI live with parents or family membersI live in public housingI live in some other stable arrangementI am incarceratedI am staying on the streets, in a car, park, sidewalk, abandoned building, or any unstable or nonpermanent situationI live in a foster care environmentNot assessed
Is youth's current living situation a temporary arrangement due to housing loss or economic hardship?
YesNoNot Assessed
Is there a second caregiver that will be participating?
YesNo
Will Anyone else be participating? (Additional Participant #1)
YesNo
Secondary Participating Caregiver Information
Person ID NO. ______________________________________
First Name:*
Middle Name:
Last Name:*
Suffix:
Date of Birth*
Gender:*
MaleFemale
Primary Phone:*
Area CodePhone Number
Primary Email:*
example@example.com
Hispanic Origin:*
HispanicNon-HIspanicUnable to Determine
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Race (select all that apply)*
American Indian/ Alaska NativeAsianBlackNative Hawaiian/Pacific IslanderUnable to DetermineDeclined to IndicateWhite
Disability Status:*
YesNoNot Assessed
Primary Language Spoken in the Home (Select One):
Marital Status
Single, Never MarriedNot married, but living together with partnerMarriedSeparatedDivorcedWidowedUnknown
Highest Education Attained:
Less than KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDid Not GraduateGraduated H.S.Received GEDPost HS Technical DegreeCompleted Associate DegreeSome CollegeCollege GraduatePost GraduateNot AssessedOther
Will Anyone else be participating? (Additional Participant #1)
YesNo
Additional Participant #1
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #2)
YesNo
Additional Participant #2
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #3)
YesNo
Additional Participant #3
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #4)
YesNo
Additional Participant #4
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #5)
YesNo
Additional Participant #5
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #6)
YesNo
Additional Participant #6
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #7)
YesNo
Additional Participant #7
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Will Anyone else be participating? (Additional Participant #8)
YesNo
Additional Participant #8
First Name:*
Middle Name:
Last Name:*
Suffix:
Gender:*
MaleFemale
Date of Birth*
Relationship to Index Child/Youth (select one)*
Parent/AdoptiveFoster ParentStepparentGrandparentAunt/UncleCousinSiblingCaregiver’s PartnerFictive KinUnrelated
Should be Empty:

PEI DIVISION CLIENT ENROLLMENT FORM

Index Child /Youth Information

Primary Participating Caregiver Information

Secondary Participating Caregiver Information

Additional Participant #1

Additional Participant #2

Additional Participant #3

Additional Participant #4

Additional Participant #5

Additional Participant #6

Additional Participant #7

Additional Participant #8