IDENTIFYING INFORMATION
YOUTH'S NAME	DATE OF BIRTH	DCN	IS THE YOUTH A PARENT? YES NO
CURRENT PLACEMENT NAME & TYPE	ADDRESS	TELEPHONE NUMBER EMAIL ADDRESS
SERVICE WORKER	COUNTY	TELEPHONE NUMBER EMAIL ADDRESS
CASE MANAGER	COUNTY	TELEPHONE NUMBER EMAIL ADDRESS
CHAFEE INDEPENDENCE SERVICES REQUESTED (AGES 14-21) YES NO THE FOLLOWING MUST HAVE BEEN COMPLETED WITHIN THE PAST 6 MONTHS: ADOLESCENT FST GUIDE & INDIVIDUALIZED ACTION PLAN (IAP) DATE COMPLETED ANSELL-CASEY LIFE SKILLS ASSESSMENT (ACLSA) DATE COMPLETED Please note: If youth has assets in excess of $10,000, youth is not eligible for Chafee Services
TRANSITIONAL LIVING GROUP HOME / SCATTERED SITE SERVICES REQUESTED YES NO THE FOLLOWING MUST HAVE BEEN COMPLETED WITHIN THE LAST 6 MONTHS: GROUP HOME ADOLESCENT FST GUIDE & IAP DATE COMPLETED SCATTERED SITE - Structured ACLSA DATE COMPLETED SCATTERED SITE – Unstructured CS-9 PACKET INCLUDED** DATE COMPLETED **MUST HAVE BEEN COMPLETED W/IN LAST 30 DAYS
CURRENTLY ENROLLED IN / RECEIVING SERVICES OR SUPPORT FROM YES NO PERFORMANCE BASED CONTRACT PROVIDER YES NO SPECIALIZED CASE MANAGEMENT PROVIDER YES NO CHAFEE SERVICES PROVIDER YES NO GUARDIANSHIP/ADOPTION SUBSIDY
ADDITIONAL COMMENTS:
NAME OF PERSON MAKING REFERRAL	SUPERVISOR SIGNATURE
DATE	DATE
CHAFEE AFTERCARE SERVICES REQUESTED YES NO RELEASE FROM CUSTODY DATE CHAFEE SUPPORT APPLICATION COMPLETED YES NO
FOR USE BY THE OLDER YOUTH TRANSITION SPECIALIST:
NAME OF OLDER YOUTH TRANSITION SPECIALIST
DATE REFERRAL RECEIVED	DATE REFERRAL FORWARDED
FORWARDED TO CFCIP PROVIDER NAME: CONTACT PERSON: TLP PROVIDER NAME: CONTACT PERSON OLDER YOUTH TRANSTION SPECIALIST FOR TRANSFER REGION
OYTS COMMENTS:

CD93 (02/10)