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The Youth Connection Career Academies RISE Program Referral Form for Youth In Transition (YIT) Closed Case Services
Please provide the following information to determine if you are eligible for YIT Closed Case Services. You MUST CLICK SUBMIT at the bottom of this form to ensure your information is received.
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Email
*
Your email
Participant's First Name
*
Your answer
Participant's Last Name
*
Your answer
Participant's Ethnicity/Race
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Black or African American
White or Caucasian
Asian or Pacific Islander
Native American or Alaskan Native
Hispanic or Latino
Multiracial, Biracial or Other Not Listed
Participant's Current Address (include Apt. # if applicable)
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Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Participant's Mailing Address (if different from current address - include Apt. # if applicable)
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
What is the BEST number to contact you?
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Your answer
Please list the name and number of someone who can always get in contact with you if your number changes, is disconnected, or you change addresses/move.
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Your answer
Participant's Date of Birth
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MM
/
DD
/
YYYY
Participant's Current Age
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Your answer
Participant's Gender
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Female
Male
Other:
Which of the following best describes you? Check ALL that apply.
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I am currently homeless and need help with emergency housing
I currently reside in safe, stable housing
Other:
Required
Which of the following YIT Closed Case Services are you interested in receiving? Please select all that apply. PLEASE NOTE: you may or may not be eligible for all or some of the services listed below.
*
Food Assistance (Assistance with food pantry, EBT/WIC, etc.)
Housing Assistance (Assistance finding housing, assistance with rent/security deposit, etc.)
Transportation Assistance (Assistance getting a car, getting your license, car insurance, etc.)
Start-Up Goods (Assistance with towels, sheets, dishes, furniture, etc.)
Baby Start-Up Goods (Assistance with baby crib/bed, diapers, clothing, etc.)
Supportive Services (Assistance with bus tickets, interview/work attire, etc.)
Help finding a job or job training
Help finding a school or college, getting enrolled to earn GED/Diploma, etc.
Other:
Required
Do you have any known challenges or barriers for which you require additional assistance? If no, type N/A.
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Your answer
How did you hear about us?
Your answer
Please choose ONLY ONE of the following:
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I am referring myself for services. If so, you do not need to complete any of the questions below. Please SCROLL DOWN & SUBMIT this referral form.
I was referred by an agency or a person. If so, please complete the following questions.
I am an agency or person who is referring a youth. If so, please complete the following questions.
IF YOU ARE REFERRING YOURSELF FOR SERVICES, you can skip this question and the following questions. Just SCROLL DOWN AND SUBMIT this referral form. If you were referred, please list the name of the Agency that referred you.
Your answer
THE FOLLOWING SECTIONS ARE TO BE COMPLETED ONLY IF BEING REFERRED BY AN AGENCY OR PERSON. List the name of the person that referred you.
Your answer
List the contact number for the referring agency or person.
Your answer
Do you have access to any of the following documents for the person being referring? Check ALL that apply.
Most Recent Court Order
Birth Certificate
Casey Life Skills Assessment - CLS (if completed within last 90 days)
Updated Service Plan (if completed within last 90 days)
DHS-902 90-Day Discharge Plan (if completed within last 90 days)
Child Assessment Needs and Strengths Plan - CANS (if completed within last 90 days)
None of the Above
A copy of your responses will be emailed to the address you provided.
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