Form 1 TLP Entrance Report

Transitional Living Program Entrance

NEORHYMIS v2.1 - TRANSITIONAL LIVING PROGRAM ENTRANCE REPORT

Expiration date 09/30/2013

OMB Control No 0970-0123

This instrument collects information regarding young people served by the Family and Youth Services Bureau (FYSB)-funded Transitional Living Programs (TLPs). (For youth to whom the Transitional Living Program staff provides services lasting fewer than 6 hours and/or who do not stay overnight, please complete the Brief Service Contact Record.)

Full and accurate reporting of information regarding youth served by TLP grantees is important because it helps to inform the U.S. Congress and funding sources about the youth whom TLPs serve and about the services TLPs provide.

For each youth who enters the TLP, please provide answers to all of the questions on this form. To answer a question, click on the appropriate response from the drop-down list box, and/or select the appropriate response. Services for youth provided prior to or outside of the TLP residential program can be reported in the TLP Exit Report under Services, item 20.

Program Name: [ Transitional Living Program ]

First Name: _________________________________________________________________

Middle Name: _______________________________________________________________

Last Name: __________________________________________________________________

Date of Birth: ______________ (mm/dd/yyyy)

NOTE: Names and birthdays should not be modified after the ID is created except by calling technical assistance at 1-(888) 749-6474.

Youth ID: [ display only ]

Center ID: [ display only ]

Updated By: [ display only ]

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

Type of Funding:	FYSB
	Other Funding Source

NOTE: Entry of non-FYSB funded youth in NEORHYMIS is optional. Such non-FYSB records are for your own use or convenience. NEORHYMIS software segregates the records automatically and they are not sent to the national FYSB database during transmission. A referral check-off is now available in the Brief Services Record to provide a rough headcount of current "system" youth (who are not included in the FYSB treatment population) whom you refer to or treat with system-funded services after they present themselves at the FYSB shelter.

TLP Entrance Date: _____________ (mm/dd/yyyy)

1. Gender: Choose one code indicating how the youth describes his/her gender identity.

1	Male (M)
2	Female (F)
3	Transgender F to M
4	Transgender M to F
5	Other
6	Not known or not determined

2. Sexual Orientation: Choose one code indicating how the youth describes his/her sexual orientation.

1	Heterosexual
2	Gay
3	Lesbian
4	Bisexual
5	Questioning/Unsure
6	Not known or not determined

3. How does the youth describe himself/herself using these census categories? On the basis of the youth's self-perception, select one or more codes indicating the young person's race category and one code indicating their ethnicity category.

NOTE: The race and ethnicity classifications below are defined by revised OMB Statistical Policy Directive No. 15. The classifications should not be interpreted as being scientific or anthropological in nature, nor should they be viewed as determinants of eligibility for participation in any Federal program. They have been developed in response to needs expressed by both the executive branch and the U.S. Congress to provide for the collection and use of compatible, nonduplicated, exchangeable racial and ethnic data by Federal agencies.

1. Race (select one or more codes)

1. _____ American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

2. _____ Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

3. _____ Black, or African American: A person having origins in any of the black racial groups of Africa.

4. _____ Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

5. _____ White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

If the following option is selected, no other race code may be entered (option #6 is no longer used):

7. _____ Not Provided: The young person did not provide information on their race.

2. Ethnicity (select one code)

1	Not Hispanic or Latino	A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
2	Hispanic or Latino	A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
3	Not Provided	The young person did not provide information on his or her ethnicity.

4. Living situation at entry: Choose one code to indicate the living situation, (this situation may be the same or different from a prevention setting, if any), in which the youth spent at least 6 of the 12 months prior to entrance. (If the youth did not spend more than 6 months at one residence during the 12 months prior to entrance, enter the code corresponding to the residence in which he or she spent the most time during that period.)

Some of the living situation categories have further type sub-classifications. If this is the case for the applicable living situation at entry for the youth, then both a code for the living situation and a code for living situation type must be selected.

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

1	In 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	On the street	1	On 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.)
		2	On the street as a throwaway youth	The young person was told to leave a stable residence by a parent or guardian, or the parent or guardian knew the young person was leaving but did not care. The young person is now 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	In 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	In 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	In a Correctional Institute or Detention Center			Secure facility operated in conjunction with the juvenile justice system.
6	In a Mental Hospital			Facility providing treatment for psychiatric illness
7	In the Military			In a facility operated by a military organization or a residence approved for military personnel
8	In 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.

5. Who referred the youth to the Transitional Living Program? Choose one code for the individual or organization through which the youth was advised about, sent, or directed to the Transitional Living Program.

Referral to Program (select one code or one code/type)

1	Self-Referral			The youth came to the agency without any direction from another person or organization.
2	Individual	1	Parent/Legal Guardian	The youth's biological parent(s), adoptive parent(s), legal guardian (s), or parent(s) who is not the youth's legal guardian.
		2	Relative or Friend	A relative other than the youth's parent or guardian or a friend of the young person.
		3	Other Adult or Youth	An adult or youth other than a relative or friend.
		4	Partner/Spouse	The young person's partner or spouse.
		5	Foster Parent	A foster parent of the youth.
3	Street Outreach Program	1	FYSB Street Outreach Program	A FYSB-funded Street Outreach Program.
		2	Other Street Outreach Program	A street outreach program not funded by FYSB.
4	Temporary Shelter	1	FYSB Basic Center Program	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	Safe Place	An organization designated as a Safe Place as part of the national Project Safe Place program. Safe Places are business and community buildings that display the diamond-shaped yellow and black Safe Place logo identifying them as Safe Place sites and are places in neighborhoods where youth can get immediate help. Safe Place sites include fast-food restaurants, convenience stores, movie theaters, and other community facilities such as fire departments, libraries, YMCAs, and Boys & Girls Clubs. In some cases, buses are designated as mobile Safe Place sites.
		6	Other Temporary Shelter	A shelter other than those described above that provides a temporary place to sleep.
5	Residential Program (Operated by Your Agency or Another Agency)	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.
6	Hotline	1	National Runaway Switchboard	The National Runaway Switchboard.
		2	Other Hotline	A hotline other than the National Runaway Switchboard.
7	Other Agency or Program (Operated by Your Agency or Another Agency	1	Child Welfare/CPS	Child Welfare or Child Protective Services.
		2	Independent Living Program That Is Nonresidential	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.
		3	Other Program Operated by Your Agency	Another nonresidential program that is run by your agency.
		4	Other Youth Services Agency	Another agency that provides nonresidential services to youth.
8	Juvenile Justice			Agencies such as juvenile courts, correctional institutions, and detention facilities, or probation and parole workers
9	Law Enforcement/Police			A legally recognized law enforcement body for a town, city, or county, such as a sheriff's department.
10	Religious Organization			Church, temple, or other organized group espousing the tenets of a spiritual or religious teaching.
11	Mental Hospital			Facility providing treatment for psychiatric illness
12	School			A school
13	Other Organization			Another organization not described above.
14	Do Not Know			Insufficient information is available to determine how the youth was referred to the agency.

6. Employment Status: Choose one code describing the youth's employment status at entrance.

1	Employed Full-Time or Part-Time	Youth is employed full-time or part-time (includes Military).
2	Seasonal/Sporadic	Youth is employed occasionally, with periods of unemployment interspersed with employment. This includes summer or holiday-specific employment.
3	Not Employed, Looking for Work	Youth is not employed and is actively looking for employment.
4	Not Employed, in School	Youth is not employed because he or she is in school.
5	Not Employed, Unable to Work	Youth is not employed because he or she is unable to work due to a physical disability, a developmental disability, or an illness.
6	Not Employed, Not Looking for Work	Youth is not employed and is not looking for employment.
7	Do Not Know Employment Status	No information is available on the youth's employment status at entrance.

7. Last Grade Completed: Choose one code corresponding to the response that best describes the last grade level completed by the youth.

1	Less than Grade 5
2	Grades 5-6
3	Grades 7-8
4	Grades 9-12
5	GED
6	Some College
7	School Program Does Not Have Grade Levels

8. School Status: Choose one code describing the youth's school status. If school was not in session at the time of the youth's entrance, this question should pertain to the school year just completed.

1	Attending School Regularly	The youth is enrolled in an educational program and attends classes regularly, without extended absenteeism.
2	Attending School Irregularly	The youth is enrolled in an educational program and attends classes 1-3 days per week on average.
3	Graduated High School	The youth has earned a high school diploma or GED.
4	Dropped Out	The youth has formally withdrawn from school prior to completing the course of study.
5	Suspended	The youth has been temporarily removed from school through official school action.
6	Expelled	The youth has been permanently removed from school through official school action.
7	Do Not Know	No information is available on the youth's school status.

9. Youth who was formerly, but is not currently, the responsibility of the child welfare or foster care agency: 

NOTE: FYSB funds are not intended to support “system” youth who are currently the responsibility of the foster care/child welfare system. Some states designate such youth as “wards of the state” (for whom the state is legal guardian). However, some youth previously in foster care have been discharged from that system or have reached an age of legal independence in your state.  (Specific rules about age, etc., vary by state.) Such youth are no longer a public responsibility and can be helped by the FYSB TLP.  For youth of this type, please answer the following question:

 

If the youth is no longer in the system but was in foster care previously in his or her life,

please select yes to indicate the youth is a former ward of the state child welfare agency:

No (default value)

Yes

If yes, then please enter the number of months or the code describing the number of years the youth was in the care of the State:

0	More than 11 months (enter years below) OR never in child welfare or foster care
1	1 month
2	2 months
3	3 months
4	4 months
5	5 months
6	6 months
7	7 months
8	8 months
9	9 months
10	10 months
11	11 months

 

Number of years (if 12 or more months, select one year code):

0	Less than 1 year (enter months above)
1	1 to 2 years
2	3 to 5 years
3	More than 5 years

10. Youth who was formerly, but is not currently, the responsibility of the public juvenile justice system: 

NOTE: FYSB funds are not intended to support “system” youth who are presently the responsibility of the juvenile justice status. However, some youth previously under the supervision or care of juvenile justice agencies have been discharged from that system or reached an age of legal independence in your state.  (Specific rules about age, etc., vary by state.) Such youth are no longer a public responsibility and can be helped by the FYSB TLP.  For youth of this type, please answer the following question:

If the youth is no longer in the system but was in the care of the juvenile justice system previously in his or her life, please select yes to indicate the youth is a former ward of the state juvenile justice system:

No (default value)

Yes

If yes, then please enter the number of months or the code describing the number of years the youth was in the care of the State:

0	More than 11 months (enter years below) OR never in child welfare or foster care
1	1 month
2	2 months
3	3 months
4	4 months
5	5 months
6	6 months
7	7 months
8	8 months
9	9 months
10	10 months
11	11 months

 Number of years (if 12 or more months, select one year code):

0	Less than 1 year (enter months above)
1	1 to 2 years
2	3 to 5 years
3	More than 5 years

11. Pregnant or Teen Parent: Is the youth currently pregnant or the parent of a child?

No (default value)

Yes

Do not know

If the youth is a parent, please provide the following information for each child:

Child Number	Child’s Date of Birth (mm/dd/yyyy)	Child’s Gender	Child Currently in Parent Youth’s Care?
1		Male	No
		Female	Yes
2		Male	No
		Female	Yes
3		Male	No
		Female	Yes
4		Male	No
		Female	Yes
5		Male	No
		Female	Yes
6		Male	No
		Female	Yes