Date of Referral:
Youth’s Name: / DOB: / Gender
Address:
Street NumberCityZip Code
Phone Number:

HomeWorkCell

Social Worker:

/ Phone No.:

Probation Officer:

/ Phone No.:

Pregnant or Parenting:

/ No Yes / Number of Children:

Persons Served by the THP-Plus-FC Program

The THP-Plus-FC Program serves NMD’s as they participate in extended foster care. THP+ FC provides the following housing options, please check housing type desired by youth:

Single Site

Single Site is one apartment building or complex, owned or leased by the provider where all of the program participants live. Single site housing can also be a house that is owned or leased by the provider in which several participants share the home.

Scattered Site

Scattered site is the leasing of apartments in various locations throughout the community, often in small clusters. The Units can be master-leased by the THP Plus Foster Care provider or participants can hold the lease separately with the landlord.

Host Family Model

In the Host Family Model, the NMD is placed with another caring adult with whom there is a permanent connection. The NMD would rent a room from the host family and the emphasis would be to engage the family to actively prepare the NMD for independent living and self-sufficiency while strengthening the permanent connection.

The THP-Plus-FC Program serves NMDs as they move from dependency to self-sufficiency and provides an opportunity to develop and strengthen permanent connections through housing and supportive services. Under W&IC section 11403(b), the NMDs can remain in foster care provided that at least one of the following participation criteria is met:

Completing high school or an equivalency program;

School / Program attending:

Enrolling in post-secondary or vocational school;

Name of Institution: / Start date:

Participating in a program or activity that promotes or removes barriers to employment;

ILP (case manager), Counseling (therapist/program), Volunteer:

Employed at least 80 hours per month or;

Employer: / Hours per month:

Is incapable of enrollment in school or employment due to a documented medical condition; written verification from a healthcare professional stating that the non-minor has a short-term or long term medical condition preventing them from participating in the above (4) requirements is necessary.

As a condition of participation in Extended Foster Care and placement in THP Plus FC, NMD’s are required to actively participate in the goals of a transitional independent living plan (TILP), which is required to be updated at least every six months and reflects goals/ activities to one of the participation requirements as described above. If NMD is not fulfilling their participation requirement, Social Worker/ Probation Officer and THP Plus FC provider need to provide reasonable efforts to ensure NMD is supported to meet requirement.

If NMD continues to be non-complaint, Social Worker/ Probation Officer will complete a JV180 to prompt an early court date to dismiss the case.

Placement History:

Please include placement history report from CWS/CMS:

Please begin with most current placement.

Date of Placement

(Beginning and Ending Months/Years) / Name and Type of Placement Facility or Family
Assessment:
Medical
  • Medical conditions
  • Date and results of last physical examination
  • Current medications (non-psychotropic (Is youth authorized to administer medications to him or herself?)
  • Use of controlled substances, alcohol and tobacco
Developmental
  • NMD’s apparent cognitive and psychosocial strengths and areas for further growth
Level of Self Sufficiency
  • Describe current examples of how the NMD is demonstrating self sufficiency
  • How often does the NMD receive support from their ILP case manager to build their independent skills
  • Describe NMD’s ability to perform day to day age appropriate activities; budget, cooking, laundry, etc…
Educational
  • Does NMD have an IEP? If so, please attach.
  • What is NMD’s current high school status?
  • What school, college, or vocational program is the youth currently enrolled in?
Mental & Emotional Status
  • History of counseling, including the name of the current therapist
  • Psychiatric hospitalizations
  • Current psychotropic medications (Is youth authorized to administer medications to him or herself?)
  • History of violent and/or predatory propensities towards others or property
  • History of suicidal ideation and/or attempt
Employment Status & Work History
  • Include length of employment, completion of certification programs, and workshops
Current Placement Status
  • Discuss the NMD’s relationships with current care providers and other residents in the home/facility
Youth’s Relationship and Visitation with Birth Family and Other Significant People
  • Discuss NMD’s potential extended family/ friends in their housing search

Office Use Only
Eligibility Verification
Completed TILP? Yes No
Placement History Report AttachedYes or No
Did youth meet criteria for THP Plus FC Yes  No
If yes, what is the projected time frame for admission to THP Plus FC?
If no, what services/support does the youth need?

The information contained in this document is confidential under Welfare and Institutions Code § 827. It is intended solely for the use of DFCS and foster youth transitional housing programs that assist current or former DFCS youth. Further dissemination of this information is prohibited.

SCZ 210.doc
File: 2nd Fastener, Right -Under / THP Plus Foster Care Placement Referral – 4/25/14
cc.: ILP Coordinator (ILP Coordinator forwards to ILP Provider if referral is accepted) / Page 1