Comprehensive Adolescent Pregnancy Prevention (CAPP) Syracuse Truce Barnabas Case Management

¨ Comprehensive Adolescent Pregnancy Prevention (CAPP)
¨ Syracuse Truce
¨ Barnabas Case Management (HPP/RHY)
¨ Barnabas House/ TILP
¨ Barnabas Shelter
¨ Transitional Apartments and Parenting Center (TAPC)

Referral Source ______Referral Name ______Phone ______
Today’s Date ______Youth Services Staff Receiving Referral ______

Youth Information
Youth’s Name ______SS # ______
Address ______(zip)______Phone ______
Age ______Gender Race ______
DOB ______¨ Male ¨ Female Language ______

Pregnant and Parenting
Is the youth currently pregnant (or expectant father) ¨ No ¨ Yes (due date ______)
Is the youth currently parenting (or non-custodial) ¨ No ¨ Yes (age of child ______)
Is the youth receiving Medicaid ¨ No ¨ Yes (Renewal date ______)

Housing
Is the youth living away from parents ¨ No ¨ Yes (if yes, how long ______)
If no, who does the youth live with (relatives, friends, shelter, etc) ______
How much longer will the youth be able to live there ______
Have you ever been homeless/ runaway in the past? ¨ No ¨ Yes
If so, when? ______

Education
Does the youth attend school ¨ No ¨ Yes
If yes: Location ______Grade ______Active: ¨ No ¨ Yes
If no: ¨ Dropped ¨ Expelled ¨ Attempting to Enroll ¨ Other

Employment or Income
Is the youth employed ¨ No ¨ Yes (Location ______)
What other income does the youth have (PA, SSI, etc) ______

Legal
Is the youth participating in the following ¨ Probation ¨ Parole ¨ Drug Court ¨ Pre-trial Release
If so, list contact information: ______
Has the youth ever been arrested? ¨ No ¨ Yes
If yes, when? ______For what? ______

Agency Information (other agencies, schools, or programs significantly involved)
Agency or School Contact Person Phone
______
______
______

Has the youth utilized TSA services in the past: ¨ No ¨ Yes
If yes, what services and when: ______
______

Revised 03/25/2015

Reason For Today’s Referral: ¨ Housing Needed Immediately ¨ Current Housing at Risk
¨ Educational Issues ¨ Employment Issues ¨ Health Issues
¨ Case Management Needed (specify) ______
¨ Mental Health Issues (specify) ______
¨ Substance Abuse Issues (specify) ______
¨ Legal Issues(specify) ______
¨ Other (specify) ______
______
Other Referrals made or resources given: ______
______

YS Office Use Only: ¨ Youth Activated ¨ Unable to Contact ¨ Youth Declined Services

¨ Youth Unwilling to Follow Through

Summarize the reason for the Referral: ______
______

Signature of Referral Source: ______Date: ______