Transitional Living Program Referral Form

907.789.7610 P.O. Box 32839

907.789.8401 Fax Juneau, Alaska 99803

Transitional Living Program Referral Form

Youth Information

Referral Date:
Name of Youth: / Age:
Phone: / Email:
Youth’s Parent/Legal Guardian (if under 18):
Phone: / Email:
Person Referring Youth: / Phone:
Position/Agency: / Email:

Eligibility Checklist

Youth is either runaway, homeless or at risk of homelessness.
Explain Current Living Situation:
Youth is 16-21 Years Old. Birth Date:
Youth is Willing to Participate in the TLP Program
Independent Living Skills that are Needed:
Current Educational/Vocational Status:
If under 18 years old, are Parents/Guardian(s) Supportive of Program Involvement?
Is youth currently receiving any medical, mental health, or substance abuse services?
Explain:
Youth is in the custody of Self or Parent/Legal Guardian.
Additional Comments:
How Did Youth Hear
About the Program?
Referral Disposition: / Staff Name:
Contact Date/Time / Contact Details

Transitional Living Program (TLP)

History:

The Transitional Living Program was created in 1997 as a means to provide youth in the community with the skills and resources necessary to live independently. In 2002, we first began providing housing at our Cornerstone apartments, serving up to 5 youth. In 2007, we opened the Black Bear Apartments, with the capacity to provide additional housing for up to 13 youth.

Program Overview:

The primary purpose of the TLP is to provide housing and independent life skill services to homeless (or potentially homeless) youth ages 16-21. The program is designed to serve youth for up to 18 months. Housing is provided at the Black Bear Apartment Building and Cornerstone Apartments. Youth receive regular daily contact/supervision with program staff. We have the capacity to house up to 18 youth. Youth under the age of 18 are provided housing at the Cornerstone Apartments.

Philosophy:

“What we have to learn to do, we learn by doing” – Aristotle

Many of the youth in our program have not had the life experience needed to live independently. We believe these youth need more time to successfully transition to “adult life.” Our program provides the opportunity to learn life skills, make mistakes along the way, and have the support and redirection of caring adults. Our goal is to help youth gain the capacity to function independently in the community, and to develop the strength, resiliency, and resources to be successful.

We use a “Housing-First” approach which maintains that stable housing is a prerequisite to achieve successful outcomes in life. With their basic housing needs addressed, youth are better able to develop life skills to ensure their successful transition to adulthood. Counseling services and referrals are provided as needed.

Program Expectations:

This is a partial list of youth/resident expectations. A Resident Participation Agreement is signed before housing is provided.

· A commitment and willingness to participate in the program.

· Youth agrees to seek employment, be employed, attend school, or a combination thereof, while in the program.

· Youth pay 30% of their net monthly income each month to JYS as a condition of participation. Volunteer work opportunities are available for youth who don’t have jobs.

· Zero tolerance for drugs, alcohol, weapons, violence, and abuse of any kind.

Desired Outcomes:

· Knowledge of basic life skills

· Experience in living independently

· Knowledge of money management, budgeting issues

· Increased sense of personal responsibility

· Connections to community resources

· Empowerment and a vision of a positive future

Referral Process:

Anyone, including youth, can refer a youth to the Transitional Living Program. Please use the attached referral form or call 523-6688 or 523-6527.

TLP Pre –Screen

Please provide the name, address, phone number, and relationship (teacher, boss, uncle, etc.) of 2 people we can contact to verify your ability to be successful in the Transitional Living Program:

Name: / Relationship to you:
Address:
Phone:
Name: / Relationship to you:
Address:
Phone:

Please tell us in a minimum of 75 words what your current living situation is, why you need/want TLP services, and what you hope to gain from the program. Use your own handwriting; use the back if needed.

Signature:

Please include a signed Release of Information for each listed reference (next two pages).

Consent/Request for Release of Information

Youth’s Name: / Date of Authorization:
Birth Date: / This release will expire on ______or 1 year from date signed.
I, / , authorize / Juneau Youth Services
Legal Guardian or Youth (if 14 years old or older)
Please initial all that apply; each section requires parent and/or youth initials. / No information will be released by the above-named person or organization to any persons or organizations unless I so authorize. I understand that the information to be released includes information regarding the following: mental health/psychiatric treatment and/or substance abuse assessment/treatment. I understand that my records are protected under federal regulation (42 CFR Part 2) governing confidentiality and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and cannot be disclosed without my written consent, except by court order, or unless otherwise provided for in regulation or notice of privacy practices. I understand I may revoke this consent, in writing, at any time except to the extent that action has been taken in reliance on it, or in the instance that this release is in conjunction with criminal justice related circumstances, or as provided in JYS’ Notice of Privacy Practices. Without my express revocation, this consent will automatically expire (1) on satisfaction of the legal need for disclosure, or (2) on the stated expiration date/event. I understand that I have a right to receive a copy of this request. If I refuse to sign this request, JYS cannot refuse to provide treatment based solely on the refusal to provide this authorization. I understand the information is to be used only for the purpose stated above and that it cannot be released to any other party or person except by court order. I understand that the potential for the information disclosed to be subject to disclosure by the recipient and no longer protected. This Release of Information can include written, verbal, and/or electronic information to or from the above-mentioned person or agency.
Legal Guardian / Youth / This release is to send info to or to receive from the following agency or individual: Name & Address
Please Initial
Legal Guardian / Youth / This information is for the purpose of:
*Youth must initial if 14 years old or older
Continued Treatment
Personal Use
Legal
Other (please specify):
Please Initial
Legal Guardian / Youth / This release includes the following Information or Documents: * Youth must initial if 14 years old or older
Assessments
Treatment Plans and Reviews
Exit Summary
Psychiatric Evaluation and Testing
Psychological Testing
Lab Work
Urinalysis (UA) Results
Incident Reports
Education
Placement Committee Recommendations
Other (please specify):
Please Initial
Youth’s Signature (required for youth 14 years old or older): / Date:
Legal Guardian’s Signature: / Date:
Witness: / Date:

This information is being released to you from records whose confidentiality is protected by Federal Confidentiality Regulations (42 CFR Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), prohibiting you from making any further disclosure of this information except with the specific written consent of the person with whom it pertains. A general authorization for the release of medical or other information, if held by another party, is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Federal Confidentially Regulations state that any person who violates any provision of this law shall be fined not more than $500 for the first offense, and not more than $5000 for subsequent offense(s).