Form 1 TLP Exit Report

Transitional Living Program Exit Report

NEORHYMIS v2.1 - TRANSITIONAL LIVING PROGRAM EXIT REPORT

Expiration date 09/30/2013

OMB Control No 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 exits 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 ]

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. 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 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.

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 TLP 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. ______ Pregnant or Teen Parent: Were services provided to a pregnant or parent?

If yes, please select one or more responses, as appropriate:

1. ______ Prenatal care

2. ______ Birthing care

3. ______ Post-natal care

4. ______ Nutrition/WIC

5. ______ Child care

21. ______ Services to Non-resident or “Pre-Resident” Youth.

(NOTE: Parts of this section, specifically “Assessment” and “Transitional Life Planning” may apply to most youth in the program since assessment at entry and planning shortly thereafter is commonly considered good practice).

Please select one or more responses, as appropriate.

1. ______ Assessment prior to TLP entry: The youth’s needs and capabilities were assessed prior to admission to TLP in preparation for an expected opening in the TLP residency. Assessment may mean psychological or vocational testing, fact finding, counseling, or other activities that can determine if a TLP residency is in the youth’s best interest and as part of developing a Transitional Living Plan. Substance abuse assessment is also reported under Services, item 10. An inventory of assessment tools developed by the National Clearinghouse on Families and Youth is available on request from the NEORHYMIS hotline at 1-888-749-6474.

2. ______ Assessment during TLP residency: The youth’s needs and capabilities were assessed as part of the service during TLP residency. Substance abuse assessment is reported separately under Services, item 10.

3. ______ Transitional Life Planning: The youth, in collaboration with TLP staff, professional counselors and/or mentors, created and agreed on a Transitional Living Plan before or shortly after moving into the TLP (often with assessment as a important element of the plan). Transitional Living Plans for all TLP youth are statutorily required by the Runaway and Homeless Youth Act.

NOTE: Transitional Living Plans can be more successful when the youth is involved as a co-creator and partner. Plans may be creative, utilizing features that appeal to young people, such as sports, music or cultural themes, scrapbooks or password-protected, personalized internet pages or on the TLP’s internal network. These plans may be revised on an ongoing basis in response to opportunities or adjust to circumstances. The “Positive Youth Development Approach” to youth services (http://www.acf.dhhs.gov/programs/fysb/content/positiveyouth/) emphasizes that assets, strengths, goals and other capacities of young people should factor into planning. The focus should not be dominated by issues, problems, and deficits of the youth, which may be addressed in an affirmative, developmental context.

4. ______ Services in settings apart from the TLP: The youth received services besides assessment, such as counseling, recreation, nutrition, etc., while not residing in the TLP, either prior to joining or during a period of stand-by, a temporary leave of absence, respite, or while on a wait list (e.g., during the situation in the next field).

If the youth never formally enters the TLP, but received services other than casual or drop-in contact, NEORHYMIS reports should be created. This situation would usually indicate a “Program Completion” status of 2 (left voluntarily with an opportunity) or 3 (left voluntarily with no plans). Even if the youth in this latter status had a transitional living plan developed, he or she did not intend or appear to follow it.) NOTE: Specific non-residency activities can be reported under other options in this “Services Provided” section along with services provided during residency.

5. ______ Respite, temporary leave of absence, standby or involuntary separation: After joining the TLP as a resident, the youth was referred to a safe and appropriate living situation on a temporary or conditional basis. This may be by agreement between the youth and the program or involuntarily because of serious infractions or potential harm. The period of non-residency does not count as part of the statutory time-limited eligibility for TLP. It is advisable to stay connected with the youth during these periods. There is no FYSB standard of practice for these situations nor for the length of absence. TLP should use discretion to assess each youth and situation to determine if an invitation to return in the future may be appropriate.

NOTE: When return is possible, the NEORHYMIS Exit Report should not be opened or completed. In cases of permanent involuntary discharge or unmistakable voluntary departure which will not involve return, please provide information about the Living Situation at Exit and Program Completion Status in the following sections and finalize the TLP Exit Report. If a youth’s case has been closed with an exit report after a long absence, then the youth reappears unexpectedly, start a new entrance record for the youth. NEORHYMIS will create the same Youth ID in a new record.

3. Living Situation at Exit: Choose one code that describes where the youth will go upon leaving the Transitional Living Program.

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, and 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. 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, and 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.
		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 TLP), 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.

4. Program Completion Status: Choose one code describing the youth's program completion status at exit.

1	Completed Transitional Living Program	The youth completed the term and plan of services developed for his or her TLP tenure.
2	Voluntarily Did Not Complete Transitional Living Program Because of Other Opportunities	The youth voluntarily terminated from the program to pursue employment or educational opportunities or a suitable independent living opportunity.
3	Voluntarily Did Not Complete Transitional Living Program, No Plans	The youth voluntarily terminated from the program, but had no definite plans (or if a Transitional Living Plan was developed, he or she did not intend or appear to follow it.)
4	Youth Was Expelled or Otherwise Involuntarily Discharged From Program	The youth was involuntarily terminated from the program with no plan or invitation to return.

5. Employment Status: Choose one code describing the youth's employment status at exit.

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.

6. 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

7. School Status: Choose one code describing the youth's school status. If school was not in session at the time of the youth's exit, 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.
4	Obtained GED	The youth has earned a General Equivalency diploma.
5	Dropped Out	The youth has formally withdrawn from school prior to completing the course of study.
6	Suspended	The youth has been temporarily removed from school through official school action.
7	Expelled	The youth has been permanently removed from school through official school action.
8	Do Not Know	No information is available on the youth's school status at exit.

8. Physical Health Status: Choose one code that best portrays the youth's physical health status at exit. (The examining health professional should be a certified practitioner but need not be an MD.)

1	Good	An examination by a medical professional reveals the youth is in good physical health.
2	Not Good	An examination by a medical professional reveals the youth is not in good physical health.
3	Not Known	A medical professional was not consulted.

9. Dental Health Status: Choose one code that best portrays the youth's dental health status at exit. (The examining dental health professional should be a certified practitioner but need not be DDS.)

1	Good	An examination by a dental professional reveals the youth's dental health is good.
2	Not Good	An examination by a dental professional reveals the youth's dental health is not good.
3	Not Known	A dental professional was not consulted.

10. Mental Health Status: Choose one code that best portrays the youth's mental health status at exit. (The examining mental health professional should be a certified practitioner but need not be MD.)

1	Good	An examination by a mental health professional reveals the youth is in good mental health.
2	Not Good	An examination by a mental health professional reveals the youth is not in good mental health.
3	Not Known	A mental health professional was not consulted.

Child Number	Child’s Date of Birth (mm/dd/yyyy)	Child’s Gender	Child Currently in Parent Youth’s Care?	Child’s Health Status
1		Male	No	Good
		Female	Yes	Not Good
				Not Known
2		Male	No	Good
		Female	Yes	Not Good
				Not Known
3		Male	No	Good
		Female	Yes	Not Good
				Not Known
4		Male	No	Good
		Female	Yes	Not Good
				Not Known
5		Male	No	Good
		Female	Yes	Not Good
				Not Known
6		Male	No	Good
		Female	Yes	Not Good
				Not Known

11. Child of Pregnant or Teen Parent Health Status: Choose one code that best portrays the health status of the child or children (if any) of the youth at exit. (The examining health professional should be a certified practitioner but need not be an MD.) NOTE: Other data associated with the youth’s child(ren) is entered on the Transitional Living Entrance form.