Form 1 BCP Exit Report

NEORHYMIS v2.1 BASIC CENTER PROGRAM EXIT REPORT

Expiration date 09/30/2013

OMB Control No 0970-0123

Program Name: [ Basic Center Program ]

First Name: [ display only ]

Middle Name: [ display only ]

Last Name: [ display only ]

Date of Birth: [ display only mm/dd/yyyy ]

Youth ID: [ display only ]

Center ID: [ display only ]

Updated By: [ display only ]

Updated Date: [ display only mm/dd/yyyy ]

Type of Funding: [ display only ]

Preventive Services (if any) Start Date: [ display only mm/dd/yyyy ]

BCP Shelter Entrance Date: [ display only mm/dd/yyyy ]

BCP Service Exit Date: ______________ (mm/dd/yyyy)

1. Young Person’s Critical Issues: Choose all codes that describe the young person's critical issues, as identified by staff and the young person during period of services. It is not necessary to check a response under each heading. These categories are for reporting purposes and are therefore general and broad. Agency case management practice should reflect more precision.

1. ______ Household Dynamics: Issues related to interactions and interrelationships within the household (for example, frequent arguments between household members.)

2. ______ Sexual Orientation/Gender Identity: Issues related to the sexual orientation or gender identity of (select one or both):

______ Youth
______ Family member(s)

3. ______ Housing Issues: Issues related to lack of sufficient housing or shelter for (select one or both):

______ Youth
______ Family member(s)

4. ______ School and Educational Issues: School or educational issues involving (select one or both):

______ Youth
______ Family member(s)

5. ______ Unemployment: Unemployment issues of (select one or both):

______ Youth
______ Family member(s)

6. ______ Mental Health Issues: Issues related to the mental health status of (select one or both):

______ Youth
______ Family member(s)

7. ______ Health Issues: Issues related to the physical well-being of (select one or both):

______ Youth
______ Family member(s)

8. ______ Physical Disability: Issues related to a physical disability or impairment experienced by (select one or both):

______ Youth
______ Family member(s)

9. ______ Mental Disability: Issues related to a mental disability or impairment of (select one or both):

______ Youth
______ Family member(s)

10. ______ Abuse and Neglect: Physical, sexual, or emotional abuse, or neglect of (select one or both):

______ Youth
______ Family member(s)

11. ______ Alcohol and Other Drug Abuse: Any abuse of alcohol, or legal or illegal drugs by (select one or both):

______ Youth
______ Family member(s)

12. ______Insufficient Income to Support Youth: Issues related to insufficient incomes of the parents/legal guardians to support the basic needs of the youth (e.g. food, clothing, and shelter).

13. ______Incarcerated Parent of Youth: Is the parent or legal guardian of the youth currently incarcerated?

If yes, please select one of the following :

______One of two parents/legal guardians is incarcerated

______Both parents/legal guardians are incarcerated

______The only parent/legal guardian (single guardian) of the youth is

incarcerated

14. ______Pregnant or Teen Parent: Issues related to the youth being pregnant or the parent of a child.

2. Services Provided to Youth by or Through the Basic Center Program: Choose all cases that describe the services provided to the young person through the Basic Center Program. It is not necessary to check a response under each heading. These categories are for reporting purposes and are therefore broad. Agency case management practice should reflect more precision. Except for number 17 (aftercare), if a service was “refused,” it should not be listed, unless a viable portion of the service was delivered prior to refusal.

1. ______ Counseling/Therapy: The provision of guidance, support, and advice designed to address interfamilial problems or help youth decide on a future course of action. (Examples of counseling/therapy include crisis intervention, individual youth counseling, home-based services, group counseling, outdoor adventure/challenge activities, expressive/art therapy, and mediation.)

2. ______ Basic Support Services: Includes provision of food, clothing, shelter, transportation, etc.

3. ______ Peer (Youth) Counseling: Counseling provided by trained youth volunteers or youth staff to the young person.

4. ______ Education: Includes learning disability assessment, tutoring, GED preparation, local school enrollment, vocational education, etc.

5. ______ Life Skills Training: Includes formal and informal coaching and training in communications skills, health promotion, conflict/anger management, assertiveness, goal setting, budgeting, life planning, nutrition, hygiene, etc.

6. ______ Employment Services: Includes services related to helping young people obtain and retain employment, such as assessment, coaching, filling out applications, interviewing, practicing and conducting job searches, referrals, and job maintenance skills.

7. ______ Physical Health Care: Provision of general health care or surgical services by licensed medical practitioners. May include prenatal testing, STD testing, and other types of health screening.

8. ______ Dental Care: Provision of dental services by a licensed dentist or other oral health specialist.

9. ______ Psychological or Psychiatric Care: Provision of assessment or treatment services by a licensed/certified medical mental health professional or professional psychologist.

10. ______ Substance Abuse Assessment and/or Treatment: Comprehensive assessment of an individual's current or past involvement with alcohol and/or drugs and/or provision of treatment, including screening, aimed at stopping their substance abuse.

11. ______ Substance Abuse Prevention: Includes activities related to alcohol and drug abuse prevention, such as education, group activities, peer coaching, refusal skills, etc.

12. ______ Legal Services: Legal services or guidance provided through an attorney or an attorney-supervised paralegal.

13. ______ Parenting Education: Services designed to build improved parenting skills that are provided to (select one or both):

1. ______ Youth with Children

2. ______ Parent of Youth

14. ______ Recreational Activities: Includes sports, arts and crafts, field trips, nature hikes, etc.

15. ______ Support Groups: Participation in one or more support groups, such as Alateen, Alcoholics Anonymous, Alanon, or a faith-based group.

16. ______ Community Service/Service Learning (CSL): Activities that involve youth in helping others or the community. A discussion of CSL, positive youth development and a variety of related options to explore is available on request from the NEORHYMIS hotline at 1-888-749-6474.

17. ______ Transitional, Exitcare or Aftercare Plans and Actions:  A plan developed for the period during and after the young person has exited the program. (NOTE: Current law requires all BCP youth to be provided an aftercare plan.)  If YES, please check one or more of the following features or related activities. If referral to mainstream or non-agency assistance programs is part of aftercare, please also respond to question 18. If mentoring is part of aftercare service, please also respond to question 19.

1. ____ A written transitional, aftercare or follow-up plan or agreement has been worked out with the youth, understood, and agreed to.

2____ Advice about and/or referral to appropriate mainstream assistance programs has been provided (further information can be supplied under question 18, “program connection”).

 3. ____ Placement in appropriate, permanent, stable housing (not a shelter) or residency accommodations has been arranged. (This option goes beyond mere referral to mainstream housing assistance alluded to in 2. and assumes the youth is eligible for and guaranteed an immediately available or reserved slot, with a waiting period for reserved accommodations of no longer than 2 weeks and suitable interim arrangements).

4. ____ Due to unavoidable circumstances or scarcities of appropriate housing, the youth must be transported or accompanied to a temporary shelter that can provide age-appropriate safety, security and services, and supervision if advisable.

5. ____ Exit counseling has been provided, including, at minimum, a discussion between staff and the youth of exit options, resources, and destinations appropriate for his/her well being and continued progress, possibly including continued follow-up, such as the next two actions.

6. ___A course of future follow-up treatment or services (e.g., incremental family reunification, formal or informal counseling, etc.) has been prescribed and scheduled, via referral, or on a non-residential, drop-in, or appointment basis.

7. _____ A follow-up meeting or series of staff/youth meetings or contacts has been scheduled to be held after youth has departed the BCP program.

8. _____ A “package” with such things as maps, information about local shelters and resources, a phone card, fare tokens, healthy snacks, etc., has been provided.

9. ______ Other.

10. ______ The youth refused or declined any and all of the above aftercare/exitcare services (including any listed as “other”)

18. ______ Program Connection: Has the youth been connected to other federal, state, local, or privately funded non-residential cash or non cash assistance programs (NOTE: residential programs, such as Job Corps, are included under living situation at exit)? If YES, please check one or more of the following:

1. ______ HUD Section 8 or other permanent housing assistance

2. ______ TANF or other welfare or non-disability income maintenance program

(all TANF services, including transportation and childcare are included)

3. ______ SSI or disability assistance

4. ______ Medicaid

5. ______ S-CHIP

6. ______ Food Stamps or other non WIC nutrition

7. ______ WIC

8. ______ Childcare (Non TANF)

9. ______ Unemployment insurance

10. ______ Workforce development services (e.g., WIA)

11. ______ Mentoring program other than RHY agency (federal, state, local or

private; for RHY agency mentoring, please respond to question 19.)

12. ______ National Service (e.g., Americorps, VISTA, Learn and Serve)

13. ______ Non residential substance abuse treatment or mental health program

14. ______ Other public federal, state or local program

15. ______ Private non-profit charity or foundation support

16. ______ Individual Development Account

Firststep: A tool to assist case managers and outreach workers to access Federal benefits for their homeless clients (http://www.cms.hhs.gov/Medicaid/homeless/firststep/index.html)

19. ______ Mentoring youth during and/or after their term of services. 

 (NOTE: Mentoring is a one-to-one supportive relationship between a youth and a caring adult who has been screened, trained with appropriate skills, and who receives follow-up supervision and support by the agency.  Group activities with other mentors can be valuable, but the one-to-one relationship is paramount.  Information on effective mentoring practices can be found at www.mentoring.org.).

20. ______ Setting of Service Delivery: Preventive services (home or non-shelter-based) or on-site BCP shelter services. Check one or more of the following preventive service options, depending on the assistance provided the youth. If the youth receive BCP shelter services ONLY, please select option 20.7 below.

This is a required element under BCP “Services Provided.”

NOTE: If at the end of the period of services, the youth runs away (not to the BCP) or successfully insists upon a living situation other than the chosen placement, the final setting would be recorded under Living Situation at Exit when the BCP Exit Report is completed.

Preventive Services:

“Preventive services” refers to counseling and other acceptable means of risk reduction to keep the youth from running away or engaging in other risk behaviors, or being placed in the child welfare or juvenile justice system unless this is in the youth’s best interest. These services may include mediation or other interventions to help build healthy relationships within the family or household) and/or referrals to promote healthy development or strengthen the youth’s assets.

1. _______ In-home Preventive Services: Preventive services were provided by the grantee on an in-home basis to the youth and/or the family or guardianship household and not at BCP shelter or other grantee facility unless also indicated below. The youth did not stay overnight at a shelter continued to reside at the original household.

2. _______ Out-of-home Preventive Services: Services were provided by the grantee to the youth off-site in the home of a relative or other responsible individual, school setting, faith-based organization, community counseling or youth center not affiliated with the grantee, or in another “neutral zone.” The youth did not stay overnight at a shelter during the period these services were provided and continued to reside at the original household.

3. _______ Overnight, Interim, Respite, or Very Limited BCP Shelter Stay with Return Home Expected Soon: The youth was provided not more than a few nights of interim, provisional accommodations at the BCP shelter (for respite, but not as a full program participant although within the care and supervision of the program). This experience could be for a “cooling off” period or during transfer to an appropriate permanent living setting. The expectation is that the youth returns to the original household or alternative permanent living situation in the following day or few days.

4. _______ Temporary Stay or Respite at a Setting Outside the Youth’s Home but Not in BCP: The youth was provided temporary or respite living arrangements at an alternative out-of-the-home setting arranged by the grantee and the youth’s family or guardian. As in the previous situation, this could be for a “cooling off” period or during transfer to an appropriate permanent living setting. The expectation is the youth returns to the original household or alternative permanent living situation at the end of the temporary period.

5. _______ Formal Placement in an Alternative Setting Other Than the BCP Shelter or the Original Home/Housing: It was determined that the interests of the youth would best be served by placement away from the household of residence and not in the BCP shelter. The new living situation should be safe, appropriate and suitable to the needs and development of the youth.

6. _______ Admission to BCP Shelter Services for More Than One Night After Receiving Preventive Services: The youth was provided more than one night of temporary shelter (full intake at the BCP shelter) after prevention efforts during a crisis intervention period, with anticipation of reunification with the family or in an alternative placement. The youth may have previously received any combination of preventive services. Please enter the date the youth formally entered the BCP shelter.

BCP Shelter Entrance Date: ______________ (mm/dd/yyyy)

BCP Shelter Services (on-site):

Please select the following option only if the youth did not receive preventive services and entered the BCP shelter directly with full intake processing.

7. _______ Direct Entry to the BCP Shelter for One or More Nights: Shelter services include direct referrals to on-site services for one or more nights with full admission processing. No preventive services were feasible or appropriate. The youth arrived or was referred directly to BCP shelter services and did not reside in the household of origin during the period he or she received BCP shelter and other services.

3. Living Situation at Exit: Choose one code that describes where the youth will go upon leaving the Basic Center Program at the conclusion of the periods described under 20 above.

Living Situation at Exit (select one code or one code/type)

1	To a shelter	1	FYSB Basic Center	FYSB-funded program providing core services (shelter, food, clothing, and counseling) to runaway and homeless youth. Basic Center services may be provided in one central location, such as a group home residence, or in decentralized locations. Federal guidelines dictate that youth may stay at Basic Centers for up to 2 weeks using FYSB funding.
		2	Other Youth Emergency Shelter	Non-FYSB-funded program providing core services (shelter, food, clothing, and counseling) to runaway and homeless youth. Shelter services may be provided in one central location, such as a group home residence, or in decentralized locations.
		3	Homeless Family Center	A program designed to provide shelter and services to homeless families.
		4	Homeless Shelter	A program designed to provide shelter and services to homeless individuals.
		5	Other Temporary Shelter	A shelter not described by any of the above that provides a temporary place to sleep.
2	To the street as a runaway or homeless youth			The young person is on the street or in a facility that has become an informal shelter for runaway and homeless youth and adults. (The informal shelter may be an apartment the leaser allows to be used, an abandoned building, a 24-hour business, or another location. It usually is temporary, and may be operating illegally.)
3	To a Private Residence	1	Living Independently	The youth lives on his/her own and has an address.
		2	Parent/Legal Guardian's Home	The residence of the biological parent(s), adoptive parent(s), legal guardian, or parent who is not the youth's legal guardian.
		3	Relative or Friend's Home	The residence of a relative other than the youth's parent(s) or a friend not related to the family.
		4	Other Adult's Home	The residence of an adult other than a relative or a friend.
		5	Other Youth's Home	The residence of a youth other than a relative or a friend.
		6	Foster Home	A temporary residence in which the youth has been legally placed by a social services agency.
		7	Partner/Spouse	A residence shared with a partner or spouse.
		8	Host Home	The residence of an adult other than a relative or a friend operated as a host home
4	To a Residential Program	1	FYSB Transitional Living Program	FYSB-funded program for older homeless youth ages 16-21 for whom it is not possible to live in a safe environment with a relative and who have no other safe alternative living arrangement.
		2	Other Transitional Living Program	Residential program that provides older homeless youth who have no other safe alternative living arrangement with the skills they will need to move to independent living.
		3	Group Home	A structured residential program that provides a homelike environment for those youth unable to return home, generally a minimum of 3 months and a maximum of 2 years stay.
		4	Independent Living Program That Is Residential	Program funded by the Children's Bureau (U.S. Department of Health and Human Services) designed to prepare youth in the foster care system to live on their own, independently from that system.
		5	Job Corps	Residential structured educational/vocational training program aimed at developing skills that will lead to self-sufficiency.
		6	Drug Treatment Center	Drug treatment centers focus on detoxification and substance abuse treatment.
		7	Residential Treatment Center	Residential treatment centers are highly structured, intensive 24-hour treatment programs that address the full range of needs of young people, including social, educational, mental health, and psychological.
		8	Educational Institute	A residence at a school, such as a boarding school or college dormitory.
		9	Other Agency Residential Program	Another residential program that is run by your agency.
		10	Other Residential Program	Residential program other than those listed above.
5	To a Correctional Institute or Detention Center			Secure facility operated in conjunction with the juvenile justice system.
6	To a Mental Hospital			Facility providing treatment for psychiatric illness
7	To the Military			In a facility operated by a military organization or a residence approved for military personnel
8	To Another Living Situation			Other living situation not described above
9	Do Not Know			The staff does not have enough information on the youth's living situation to correctly choose a response.

NOTE: It is important to connect with each youth, help them develop plans for the future, and maintain contact. However, on occasion youth abruptly leave the premises without assistance, counseling or guidance. Reconnection with the youth or news of his/her whereabouts may emerge at a later date. If this is within a “reasonable” period of time (according to the judgment of the BCP), updating or correcting the data in NEORHYMIS is strongly encouraged to change the “unknown” exit situation to the actual situation. The technical support hotline provides guidance on how to accomplish this task before or after semi- annual data transfer at

1-888-749-6474.