Youth Profile

National Extranet Optimized Runaway and Homeless Youth Management Information System (NEORHYMIS)

20070605_NEORHYMIS_V2.1_Definitions_final

Youth Profile

OMB: 0970-0123

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0123 can be found here:

Document [doc]

Download: doc | pdf

Expiration date: mm/dd/yyyy

OMB Control No: previously approved as 0970-0123

NOTE TO FYSB and CSC: Changes circa June 1, 2007, are blue; remove this line after final draft

NEORHYMIS

NATIONAL EXTRANET OPTIMIZED RUNAWAY AND HOMELESS YOUTH MANAGEMENT INFORMATION SYSTEM, Version 2.1

(data collection instrument)

This instrument is for recording and reporting the profiles of youth, their critical issues, and services they receive through the runaway and homeless youth programs authorized by the Runaway and Homeless Youth Act (P.L. 108-96). The Statute also governs the basic requirements for collecting this data.

Version 2.1 of NEORHYMIS has a few changes since Version 2.0. Many of these modifications were the result of suggestions from RHY organizations and youth serving professionals. Under “Services” BCPs may now record preventive efforts (as envisioned in the Runaway and Homeless Youth Act) to divert youth in at risk situations from leaving home without permission. It provides TLPs with options for recording “non-residential” periods when the youth may have moved out of the residency for a temporary period of respite, time-out or reassessment while continuing to receive various services from the TLP, such as counseling, meals, or special events to help them stay “connected.” Several additional services or activities have been included, such as assessment before or during the TLP residency, transitional life planning, and individual development accounts. Finally, a few additional help comments have been added to clarify definitions and situations that users often ask about.

Answers to a great many of the questions in NEORHYMIS may also be required of service providers by other funding sources (client demographics, issues, services, etc.) NEORHYMIS, like its predecessor, can be used for non-FYSB programs, if any agency wishes to use it to support their general case management. The technical assistance center (see number below) can also advise agencies how to add additional questions or modify original content if needed for a non-FYSB version of NEORHYMIS, for example, if they wish to create an instrument to serve other age groups with other types of services. FYSB will also accept RHY data submitted from other systems as long as they can be adapted into NEORHYMIS. The technical assistance center can help with these issues.

NEORHYMIS is distributed free as software to all FYSB grantees. Further information is available through the Technical Assistance Center at: Hotline: (888) 749-6474, option #1; E-mail: [email protected]. The NEORHYMIS biannual reporting periods are October 1 through March 31, and April 1 through September 30. The Federal Transfer data submission is due within the 15 days following the end of the reporting period. Data received after the 15^th will be reported as having been received after the due date and marked as "late."

A special extranet website is available for users to generate standard and custom reports on any periods of validated data from RHYMIS-LITE/NEORHYMIS since FY 2002. Access to more detailed data will be provided to federal staff, grantees, and on request to others doing research or seeking information. The site is http://extranet.acf.hhs.gov/rhymis.

THE PAPERWORK REDUCTION ACT OF 1995: Public reporting burden for this collection of information is estimated to average 1 hour per response for all the above reports, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. If an agency is not required to submit all reports, the longest report, the BCP or TLP youth profile (entrance and exit report) is estimated to require less than 1/2 hour per youth profile. A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Contents:

Basic Center Entrance Report 4

Basic Center Exit Report 16

Basic Center Turnaway Report 27

Transitional Living Entrance Report 28

Transitional Living Exit Report 39

Transitional Living Turnaway/Waiting List Report 51

Brief Service Contact Report 52

Street Outreach Contact Report 54

NEORHYMIS v2.1 - BASIC CENTER ENTRANCE REPORT

Expiration date: mm/dd/yyyy — OMB Control No: previously approved as 0970-0123

This instrument collects information regarding young people served by the Family and Youth Services Bureau (FYSB)-funded Basic Center Programs. (For youth to whom Basic Center Program staff provide services lasting fewer than 6 hours and/or do not stay overnight, please complete the Brief Service Contact Record.) Youth who are receiving FYSB funded services but are not staying at the Basic Center, may be fully recorded, and should be recorded in NEORHYMIS if the contact is more than casual or transitory. Street outreach services or “brief services” contacts should be entered in their respective NEORHYMIS reports.

Complete and accurate reporting of information regarding youth served by Basic Center Program grantees is important because it helps to inform the U.S. Congress and funding sources about the youth whom Basic Center Programs serve and about the services Basic Center Programs provide.

For each youth who enters the Basic Center Program, 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. Common elements between entrance and exit reports will be automatically generated. Services, such as prevention efforts, for youth provided prior to participation or elsewhere than the BCP shelter can be reported in the BCP Exit Report.

Program Name: [ Basic Center 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.

Settings for service delivery: Identify the setting and nature of services delivered as explained below (choose the type that applies).

Setting for Service Delivery (select one of the following codes):

1	Services to prevent shelter entry	Preventive services were provided at home or another location to serve the youth’s needs and with the goal of keeping the youth in their home. These may include: in-home services, services provided at a school, faith-based organization, community center, on the BCP premises while the youth continues to reside at home, or similar situations. These services could be provided by a variety of sources. The BCP exit report will collect information on specific services rendered.
2	Direct BCP shelter services	Direct BCP shelter services are those provided when the youth directly enters the BCP shelter without receiving prior preventive services.

Youth who are receiving a structured course of preventive services outside the shelter should be recorded in NEORHYMIS Entrance and Exit Reports as well as youth who directly enter the BCP. The opportunity to describe the course and types of preventive services is found under Services, item 20 in the BCP exit report. Such services recorded in NEORHYMIS BCP reports should be more structured than transient or casual contacts (e.g., hotline/phone or brief, drop-in counseling) recorded in the Brief Service Contact Report.

Enter the date the youth first received preventive services or directly entered the BCP shelter without prior preventive services.

BCP Service Start 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, 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, such as host homes. 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, 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, such as host homes.
		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	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.
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 Basic Center Program? Choose one code for the individual or organization through which the youth was advised about, sent, or directed to the Basic Center 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.
3	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, 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, such as host homes. 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, 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, such as host homes.
		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.
6	Hotline	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. N/A (Reserved for future modifications)

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 BCP. 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 BCP. 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

NEORHYMIS v2.1 BASIC CENTER PROGRAM EXIT REPORT

Expiration date: mm/dd/yyyy — OMB Control No: previously approved as 0970-0123

Program Name: [ Basic Center Program ]

First Name: [ display only ]

Middle Name: [ display only ]

Last Name: [ display only ]

Date of Birth: [ display only mm/dd/yyyy ]

Youth ID: [ display only ]

Center ID: [ display only ]

Updated By: [ display only ]

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

Type of Funding: [ display only ]

Preventive Services (if any) Start Date: [ display only mm/dd/yyyy ]

BCP Shelter Entrance Date: [ display only mm/dd/yyyy ]

BCP Service Exit Date: ______________ (mm/dd/yyyy)

1. Young Person’s Critical Issues: Choose all codes that describe the young person's critical issues, as identified by staff and the young person during period of services. It is not necessary to check a response under each heading. These categories are for reporting purposes and are therefore general and broad. Agency case management practice should reflect more precision.

1. ______ Household Dynamics: Issues related to interactions and interrelationships within the household (for example, frequent arguments between household members.)

2. ______ Sexual Orientation/Gender Identity: Issues related to the sexual orientation or gender identity of (select one or both):

______ Youth
______ Family member(s)

3. ______ Housing Issues: Issues related to lack of sufficient housing or shelter for (select one or both):

______ Youth
______ Family member(s)

4. ______ School and Educational Issues: School or educational issues involving (select one or both):

______ Youth
______ Family member(s)

5. ______ Unemployment: Unemployment issues of (select one or both):

______ Youth
______ Family member(s)

6. ______ Mental Health Issues: Issues related to the mental health status of (select one or both):

______ Youth
______ Family member(s)

7. ______ Health Issues: Issues related to the physical well-being of (select one or both):

______ Youth
______ Family member(s)

8. ______ Physical Disability: Issues related to a physical disability or impairment experienced by (select one or both):

______ Youth
______ Family member(s)

9. ______ Mental Disability: Issues related to a mental disability or impairment of (select one or both):

______ Youth
______ Family member(s)

10. ______ Abuse and Neglect: Physical, sexual, or emotional abuse, or neglect of (select one or both):

______ Youth
______ Family member(s)

11. ______ Alcohol and Other Drug Abuse: Any abuse of alcohol, or legal or illegal drugs by (select one or both):

______ Youth
______ Family member(s)

12. ______Insufficient Income to Support Youth: Issues related to insufficient incomes of the parents/legal guardians to support the basic needs of the youth (e.g. food, clothing, and shelter).

13. ______Incarcerated Parent of Youth: Is the parent or legal guardian of the youth currently incarcerated?

If yes, please select one of the following :

______One of two parents/legal guardians is incarcerated

______Both parents/legal guardians are incarcerated

______The only parent/legal guardian (single guardian) of the youth is

incarcerated

14. ______Pregnant or Teen Parent: Issues related to the youth being pregnant or the parent of a child.

2. Services Provided to Youth by or Through the Basic Center Program: Choose all cases that describe the services provided to the young person through the Basic Center Program. It is not necessary to check a response under each heading. These categories are for reporting purposes and are therefore broad. Agency case management practice should reflect more precision. Except for number 17 (aftercare), if a service was “refused,” it should not be listed, unless a viable portion of the service was delivered prior to refusal.

1. ______ Counseling/Therapy: The provision of guidance, support, and advice designed to address interfamilial problems or help youth decide on a future course of action. (Examples of counseling/therapy include crisis intervention, individual youth counseling, home-based services, group counseling, outdoor adventure/challenge activities, expressive/art therapy, and mediation.)

2. ______ Basic Support Services: Includes provision of food, clothing, shelter, transportation, etc.

3. ______ Peer (Youth) Counseling: Counseling provided by trained youth volunteers or youth staff to the young person.

4. ______ Education: Includes learning disability assessment, tutoring, GED preparation, local school enrollment, vocational education, etc.

5. ______ Life Skills Training: Includes formal and informal coaching and training in communications skills, health promotion, conflict/anger management, assertiveness, goal setting, budgeting, life planning, nutrition, hygiene, etc.

6. ______ Employment Services: Includes services related to helping young people obtain and retain employment, such as assessment, coaching, filling out applications, interviewing, practicing and conducting job searches, referrals, and job maintenance skills.

7. ______ Physical Health Care: Provision of general health care or surgical services by licensed medical practitioners. May include prenatal testing, STD testing, and other types of health screening.

8. ______ Dental Care: Provision of dental services by a licensed dentist or other oral health specialist.

9. ______ Psychological or Psychiatric Care: Provision of assessment or treatment services by a licensed/certified medical mental health professional or professional psychologist.

10. ______ Substance Abuse Assessment and/or Treatment: Comprehensive assessment of an individual's current or past involvement with alcohol and/or drugs and/or provision of treatment, including screening, aimed at stopping their substance abuse.

11. ______ Substance Abuse Prevention: Includes activities related to alcohol and drug abuse prevention, such as education, group activities, peer coaching, refusal skills, etc.

12. ______ Legal Services: Legal services or guidance provided through an attorney or an attorney-supervised paralegal.

13. ______ Parenting Education: Services designed to build improved parenting skills that are provided to (select one or both):

1. ______ Youth with Children

2. ______ Parent of Youth

14. ______ Recreational Activities: Includes sports, arts and crafts, field trips, nature hikes, etc.

15. ______ Support Groups: Participation in one or more support groups, such as Alateen, Alcoholics Anonymous, Alanon, or a faith-based group.

16. ______ Community Service/Service Learning (CSL): Activities that involve youth in helping others or the community. A discussion of CSL, positive youth development and a variety of related options to explore is available on request from the NEORHYMIS hotline at 1-888-749-6474.

17. ______ Transitional, Exitcare or Aftercare Plans and Actions: A plan developed for the period during and after the young person has exited the program. (NOTE: Current law requires all BCP youth to be provided an aftercare plan.) If YES, please check one or more of the following features or related activities. If referral to mainstream or non-agency assistance programs is part of aftercare, please also respond to question 18. If mentoring is part of aftercare service, please also respond to question 19.

1. ____ A written transitional, aftercare or follow-up plan or agreement has been worked out with the youth, understood, and agreed to.

2____ Advice about and/or referral to appropriate mainstream assistance programs has been provided (further information can be supplied under question 18, “program connection”).

3. ____ Placement in appropriate, permanent, stable housing (not a shelter) or residency accommodations has been arranged. (This option goes beyond mere referral to mainstream housing assistance alluded to in 2. and assumes the youth is eligible for and guaranteed an immediately available or reserved slot, with a waiting period for reserved accommodations of no longer than 2 weeks and suitable interim arrangements).

4. ____ Due to unavoidable circumstances or scarcities of appropriate housing, the youth must be transported or accompanied to a temporary shelter that can provide age-appropriate safety, security and services, and supervision if advisable.

5. ____ Exit counseling has been provided, including, at minimum, a discussion between staff and the youth of exit options, resources, and destinations appropriate for his/her well being and continued progress, possibly including continued follow-up, such as the next two actions.

6. ___A course of future follow-up treatment or services (e.g., incremental family reunification, formal or informal counseling, etc.) has been prescribed and scheduled, via referral, or on a non-residential, drop-in, or appointment basis.

7. _____ A follow-up meeting or series of staff/youth meetings or contacts has been scheduled to be held after youth has departed the BCP program.

8. _____ A “package” with such things as maps, information about local shelters and resources, a phone card, fare tokens, healthy snacks, etc., has been provided.

9. ______ Other.

10. ______ The youth refused or declined any and all of the above aftercare/exitcare services (including any listed as “other”)

18. ______ Program Connection: Has the youth been connected to other federal, state, local, or privately funded non-residential cash or non cash assistance programs (NOTE: residential programs, such as Job Corps, are included under living situation at exit)? If YES, please check one or more of the following:

1. ______ HUD Section 8 or other permanent housing assistance

2. ______ TANF or other welfare or non-disability income maintenance program

(all TANF services, including transportation and childcare are included)

3. ______ SSI or disability assistance

4. ______ Medicaid

5. ______ S-CHIP

6. ______ Food Stamps or other non WIC nutrition

7. ______ WIC

8. ______ Childcare (Non TANF)

9. ______ Unemployment insurance

10. ______ Workforce development services (e.g., WIA)

11. ______ Mentoring program other than RHY agency (federal, state, local or

private; for RHY agency mentoring, please respond to question 19.)

12. ______ National Service (e.g., Americorps, VISTA, Learn and Serve)

13. ______ Non residential substance abuse treatment or mental health program

14. ______ Other public federal, state or local program

15. ______ Private non-profit charity or foundation support

16. ______ Individual Development Account

Firststep: A tool to assist case managers and outreach workers to access Federal benefits for their homeless clients (http://www.cms.hhs.gov/Medicaid/homeless/firststep/index.html)

19. ______ Mentoring youth during and/or after their term of services.

(NOTE: Mentoring is a one-to-one supportive relationship between a youth and a caring adult who has been screened, trained with appropriate skills, and who receives follow-up supervision and support by the agency. Group activities with other mentors can be valuable, but the one-to-one relationship is paramount. Information on effective mentoring practices can be found at www.mentoring.org.).

20. ______ Setting of Service Delivery: Preventive services (home or non-shelter-based) or on-site BCP shelter services. Check one or more of the following preventive service options, depending on the assistance provided the youth. If the youth receive BCP shelter services ONLY, please select option 20.7 below.

This is a required element under BCP “Services Provided.”

NOTE: If at the end of the period of services, the youth runs away (not to the BCP) or successfully insists upon a living situation other than the chosen placement, the final setting would be recorded under Living Situation at Exit when the BCP Exit Report is completed.

Preventive Services:

“Preventive services” refers to counseling and other acceptable means of risk reduction to keep the youth from running away or engaging in other risk behaviors, or being placed in the child welfare or juvenile justice system unless this is in the youth’s best interest. These services may include mediation or other interventions to help build healthy relationships within the family or household) and/or referrals to promote healthy development or strengthen the youth’s assets.

1. _______ In-home Preventive Services: Preventive services were provided by the grantee on an in-home basis to the youth and/or the family or guardianship household and not at BCP shelter or other grantee facility unless also indicated below. The youth did not stay overnight at a shelter continued to reside at the original household.

2. _______ Out-of-home Preventive Services: Services were provided by the grantee to the youth off-site in the home of a relative or other responsible individual, school setting, faith-based organization, community counseling or youth center not affiliated with the grantee, or in another “neutral zone.” The youth did not stay overnight at a shelter during the period these services were provided and continued to reside at the original household.

3. _______ Overnight, Interim, Respite, or Very Limited BCP Shelter Stay with Return Home Expected Soon: The youth was provided not more than a few nights of interim, provisional accommodations at the BCP shelter (for respite, but not as a full program participant although within the care and supervision of the program). This experience could be for a “cooling off” period or during transfer to an appropriate permanent living setting. The expectation is that the youth returns to the original household or alternative permanent living situation in the following day or few days.

4. _______ Temporary Stay or Respite at a Setting Outside the Youth’s Home but Not in BCP: The youth was provided temporary or respite living arrangements at an alternative out-of-the-home setting arranged by the grantee and the youth’s family or guardian. As in the previous situation, this could be for a “cooling off” period or during transfer to an appropriate permanent living setting. The expectation is the youth returns to the original household or alternative permanent living situation at the end of the temporary period.

5. _______ Formal Placement in an Alternative Setting Other Than the BCP Shelter or the Original Home/Housing: It was determined that the interests of the youth would best be served by placement away from the household of residence and not in the BCP shelter. The new living situation should be safe, appropriate and suitable to the needs and development of the youth.

6. _______ Admission to BCP Shelter Services for More Than One Night After Receiving Preventive Services: The youth was provided more than one night of temporary shelter (full intake at the BCP shelter) after prevention efforts during a crisis intervention period, with anticipation of reunification with the family or in an alternative placement. The youth may have previously received any combination of preventive services. Please enter the date the youth formally entered the BCP shelter.

BCP Shelter Entrance Date: ______________ (mm/dd/yyyy)

BCP Shelter Services (on-site):

Please select the following option only if the youth did not receive preventive services and entered the BCP shelter directly with full intake processing.

7. _______ Direct Entry to the BCP Shelter for One or More Nights: Shelter services include direct referrals to on-site services for one or more nights with full admission processing. No preventive services were feasible or appropriate. The youth arrived or was referred directly to BCP shelter services and did not reside in the household of origin during the period he or she received BCP shelter and other services.

3. Living Situation at Exit: Choose one code that describes where the youth will go upon leaving the Basic Center Program at the conclusion of the periods described under 20 above.

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

1	To a shelter	1	FYSB Basic Center	FYSB-funded program providing core services (shelter, food, clothing, 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, such as host homes. 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, 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, such as host homes.
		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	To 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.)
3	To a Private Residence	1	Living Independently	The youth will live on his/her own and have 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	To 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	To a Correctional Institute or Detention Center			Secure facility operated in conjunction with the juvenile justice system.
6	To a Mental Hospital			Facility providing treatment for psychiatric illness
7	To the Military			In a facility operated by a military organization or a residence approved for military personnel
8	To 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.

NOTE: It is important to connect with each youth, help them develop plans for the future, and maintain contact. However, on occasion youth abruptly leave the premises without assistance, counseling or guidance. Reconnection with the youth or news of his/her whereabouts may emerge at a later date. If this is within a “reasonable” period of time (according to the judgment of the BCP), updating or correcting the data in NEORHYMIS is strongly encouraged to change the “unknown” exit situation to the actual situation. The technical support hotline provides guidance on how to accomplish this task before or after semi- annual data transfer at

1-888-749-6474.

NEORHYMIS v2.1 BASIC CENTER PROGRAM TURNAWAY REPORT

Expiration date: mm/dd/yyyy — OMB Control No: previously approved as 0970-0123

The Turnaway Record enables the FYSB grantees to report on the number of youth turned away due to lack of bed space and will help FYSB identify underserved communities and program capacity and resource issues.

Center ID: [ display only ]

Updated By: [ display only ]

Updated Date: [ display only ]

Reporting Period Covered

Start Date _______________________ (mm/dd/yyyy)

End Date _______________________ (mm/dd/yyyy)

No Vacancy: During this reporting period, how many young people eligible to enter the Basic Center could not do so because the Center had no vacancy?
1. Number of "turnaway" requests for assistance received by telephone.
2. Number of "turnaway" requests for assistance received in person (drop in, by appointment.)

Agencies have the option to create more than one "Turnaway" record during the reporting period, provided that each Start and End date fall within the current period being reported upon. Example: During the October/March timeframe, a new Turnaway record may be created by week, by month, etc.

If a youth was “turned away” because the youth was eligible for system services due to current foster care, juvenile justice, or mental health status, please do not record here but as a “system referral” in item 4 of the brief service contact report.

NEORHYMIS v2.1 - TRANSITIONAL LIVING PROGRAM ENTRANCE REPORT

Expiration date: mm/dd/yyyy — OMB Control No: previously approved as 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

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

1. Race (select one or more codes)

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.

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, 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, such as host homes. 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, 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, such as host homes.
		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	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.
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.
3	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, 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, such as host homes. 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, 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, such as host homes.
		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.
6	Hotline	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

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:

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

NEORHYMIS v2.1 TRANSITIONAL LIVING PROGRAM EXIT REPORT

Expiration date: mm/dd/yyyy — OMB Control No: previously approved as 0970-0123

Program Name: [ Transitional Living Program ]

First Name: [ display only ]

Middle Name: [ display only ]

Last Name: [ display only ]

Date of Birth: [ display only mm/dd/yyyy ]

Youth ID: [ display only ]

Center ID: [ display only ]

Updated By: [ display only ]

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

Type of Funding: [ display only ]

TLP Entrance Date: [ display only mm/dd/yyyy ]

TLP Exit Date: ______________ (mm/dd/yyyy)

NOTE: If the youth is temporarily absent from the program by prior arrangement with the TLP staff (e.g., “on hiatus”), then do not enter the TLP exit data. The exit record indicates that the youth has completed their current visit and is not expected to return.)

1. ______ Household Dynamics: Issues related to interactions and interrelationships within the household (for example, frequent arguments between household members.)

2. ______ Sexual Orientation/Gender Identity: Issues related to the sexual orientation or gender identity of (select one or both):

______ Youth
______ Family member(s)

3. ______ Housing Issues: Issues related to lack of sufficient housing or shelter for (select one or both):

______ Youth
______ Family member(s)

4. ______ School and Educational Issues: School or educational issues involving (select one or both):

______ Youth
______ Family member(s)

5. ______ Unemployment: Unemployment issues of (select one or both):

______ Youth
______ Family member(s)

6. ______ Mental Health Issues: Issues related to the mental health status of (select one or both):

______ Youth
______ Family member(s)

7. ______ Health Issues: Issues related to the physical well-being of (select one or both):

______ Youth
______ Family member(s)

8. ______ Physical Disability: Issues related to a physical disability or impairment experienced by (select one or both):

______ Youth
______ Family member(s)

9. ______ Mental Disability: Issues related to a mental disability or impairment of (select one or both):

______ Youth
______ Family member(s)

10. ______ Abuse and Neglect: Physical, sexual, or emotional abuse, or neglect of (select one or both):

______ Youth
______ Family member(s)

11. ______ Alcohol and Other Drug Abuse: Any abuse of alcohol, or legal or illegal drugs by (select one or both):

______ Youth
______ Family member(s)

12. ______Insufficient Income to Support Youth: Issues related to insufficient incomes of the parents/legal guardians to support the basic needs of the youth (e.g. food, clothing, and shelter).

13. ______Incarcerated Parent of Youth: Is the parent or legal guardian of the youth currently incarcerated?

If yes, please select one of the following :

______One of two parents/legal guardians is incarcerated

______Both parents/legal guardians are incarcerated

______The only parent/legal guardian (single guardian) of the youth is

incarcerated

14. ______Pregnant or Teen Parent: Issues related to the youth being pregnant or the parent of a child.

2. Services Provided to Youth by or Through the Transitional Living Program:

Choose all cases that describe the services provided to the young person through the Transitional Living Program. It is not necessary to check a response under each heading. These categories are for reporting purposes and are therefore broad. Agency case management practice should reflect more precision. Except for number 17 (aftercare), if a service was “refused,” it should not be listed, unless a viable portion of the service was delivered prior to refusal.