16 Years Old

Independent Living Staffing Outcomes
Date of Staffing
Name of Youth
DOB/Age
CDS ILFCC
Current School/Placement
PFSF Family Care Counselor

Type of Staffing

16 year old

16 ½ year old

Child’s primary language: __

Translator needed?: No Yes and the following arrangements were made to accommodate.

Is the Child Deaf or Hearing Impaired? No Yes

Translator needed?: No Yes and the following arrangements were made to accommodate.

Does the youth have a copy of:

Birth Certificate Yes No

Social Security Card Yes No

Florida Identification Card/Valid Drivers License Yes No

Medicaid Card Yes No

Youth’s Educational & Career Path (Based on F.A.C.T.S.org) ______

______

IL ASSESSMENT RESULTS

Strengths (please list) / Areas for Improvement (please list)
Skills Training Plan Effective Date
Skills Training Plan Target Date

*ATTACH COPY OF CURRICULUM

Skills Training Information Provided to Youth? Yes No

Skills Training Information Provided to Foster Parent? Yes No

Is the youth actively involved with IL Life Skills? YES NO

If yes, what are some of the classes that the youth has completed since the last staffing?

What additional IL services are needed at this time?

If no, what is preventing the youth from completing IL Life Skills training?

______

HEALTH STATUS

MENTAL HEALTH SERVICES

Is the youth receiving mental health services? Yes No

If yes, what is the current mental health diagnosis?

Does the youth wish to continue to receive mental health services after their 18th birthday? YES NO

Will the youth need assistance with referral for mental health services after 18th birthday?

YES NO

Who will provide these services to the youth?

Developmental Disability Services

Does the youth have a developmental disability? Yes No

If yes, has the youth been referred to Developmental Disabilities (APD)?

Who will help the youth apply for benefits?

If applied what is the status of the application?

What documented efforts have been made to ensure that the youth is connected to services when they age out?

What services will the youth be receiving?

Who will provide these services to the youth?

Social Security Benefits

Is the youth receiving SSI/SSA benefits? YES NO

If yes, please explain why?

Has the youth or case manager applied for Social Security benefits? YES NO

Who will help the youth apply for benefits?

If applied what is the status of the application?

Has the youth been provided information related to continuing SSI/SSA benefits?

YES NO

If youth is receiving benefits, has he/she been provided with an accounting of funds in the trust and how to access these funds? YES NO

HEALTH CARE

Does the youth have a regular physician that they can contact if needed? YES NO

Does the youth have a regular dentist that they can contact if needed? YES NO

Will the youth need to apply for KidCare after their 18th birthday? Yes NO

Who will assist the youth with the application?

EDUCATIONAL STATUS

School Attending/Grade
Grade Point Average
Expected Graduation Date

*ATTACH COPIES OF REPORT CARDS

What type of diploma is the youth pursuing?

General High School Diploma

Special Option I High School Diploma

Special Option II High School Diploma

General Education Diploma (GED)

If youth is enrolled in Special Education classes, when was the last IEP completed? ______

Please attach most recent IEP to staffing form

GOAL PLANNING

___ Entering the 9th grade ____ Initial Goal Planning ____ Goal Change

Px strengths, needs, abilities and preferences (SNAP):
S.
N.
A.
P.

Post- Secondary Educational Goals:

Choose one of the following:

Attending a 4-year college or university, a community college plus university,

or a military academy

Receive a two-year post secondary degree

Attain a post-secondary career and technical certificate

Begin employment immediately after completion of high school diploma or its

equivalent or enlist in the military.

Post-Secondary Educational Information Provided to Youth? Yes No

What educational institution would the youth like to attend?

What educational courses are you currently taking that will help you work toward your educational goals?

EMPLOYMENT STATUS

Currently Employed? Yes No

If yes, where?

Does the youth have any other sources of income?

How much does the youth earn weekly/monthly?

Past employment experience:

What is the youth’s career goal?

Short- term goal (Within the next six months)

Long-term goal (Within the next five years)

MENTORING/INTERNSHIPS

Identified Mentor’s name (teacher, employee of DCF/PFSF/CDS or community volunteer):

Identified Internship(s) and/or volunteer work:

BANK ACCOUNT

Does the youth have an opened bank account? Yes No

If yes, amount saved? ______

Additional Information (including plans to open a bank account):

TRANSPORTATION

How will the youth get to work and school?

What efforts are there to assist youth in this?

PERMANENCY ARRANGEMENTS

What are the permanency arrangements and the child’s wishes regarding adoption?

Any other identified obstacles and needs the child has with regard to IL.:

THE FOLLOWING ACTIONS NEED TO TAKE PLACE

BEFORE THE NEXT REVIEW:

Foster Parent(s)/Group Home Staff:

1. Ensure youth is present for life skills training.

2. Cooperate with life skills training home assignments for the youth.

3. Communicate with ILP staff to discuss ILP progress and difficulties.

PFSF Family Care Counselor:

1. Communicate with ILP staff on youth’s placement status and school progress.

2. Assist ILP staff in obtaining verification of life skills training youth may receive at school.

3. Assist youth in obtaining either a Florida State Photo ID or driver’s license.

CDS Independent Living Staff:

1. Continue to provide independent living life skills training to youth.

2. Maintain communication with the PFSF Family Care Counselor to monitor youth’s placement status and educational progress.

3. Provide BI-ANNUAL STAFFINGS FOR YOUTH.

Youth:

Youth:

1. Continue to attend school on a regular basis and attempt to maintain a 2.0 GPA.
2. Continue to attend life skills training and complete all home assignments for life skills training.

I understand that by signing this document, I am beginning to plan for my future. I understand that the educational goal marked above can be changed at anytime. Signing

I understand that by signing this document, I am beginning to plan my future. I understand the educational goal marked above can be changed at any time. Signing

this does not lock me into a plan, but rather helps me to begin to plan for my future education. I have reviewed all options at this time and agree that the educational goal marked above is my choice at this time. I will continue to plan for my future with the assistance of the CDS Independent Living staff, my PFSF Family Care Counselor, foster parent or other mentor.

I have been given information on:

Scholarships (Bright Futures) Grants

PESS Fee Waiver/Exemption

Aftercare Funds

Concur With Plan / Title / Signature/Printed Name
Yes No / Youth
Yes No / Foster Parent
Yes No / PFSF Family Care Counselor
Yes No / CDS IL Staff
Yes No / IL Coordinator.
Yes No / Therapist
Yes No / Other
NEXT STAFFING WILL OCCUR

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Rev 10/11 F-PR1307