SHY Office Use Only Client Code:______Entry Date:______ILS Counselor:______Program Enrolled: ___351 __United Way __DHS THP __Morgan Family __FHPAP ___350 __DHS Healthy Transition Referred not served date: ______Added to Referral list? Y or N If yes, ___ Scattered Site ___ Ebed ___ Transitional Reason not served: ______Resources Given______Time spent with client: ______Backpack given? Y or N Hygiene Pack ? Y or N SHY PROGRAM REFERRAL/ENTRY INFORMATION Youth Name ______Referral date ______Date Needing Housing______Gender: __Male __Female __Transgender Age: _16 _ 17 _ 18 _ 19 _ 20 _ 21 _ 22 _23 _24 Current Address______Phone #______Social Security #______DOB______E-mail ______County______Pregnant ______Due date______# of children______State Born______Do you identify as GLBTQ2-S? ____Yes _____No Has the youth been in an out of home placement after the age of 14 years for at least 30 days? Yes No Not Sure If yes, what county authorized that placement? ______If yes, was this placement chemical dependency or juvenile detention? Yes No Not Sure

Race: ___Native American/Alaska Native ___Multiracial ___Hispanic ___Black ___Asian/Pacific Islander ___White Referral Source: __Self __Drug/alcohol program __Police __Street outreach worker __Other medical __Public Housing Waiting List __Shelter Staff __Social Services ___Church staff __Psych hosp __Probation __Other ______SAIL Program __Mental Health - out-patient

Living Situation: __Substance Abuse Treatment __Domestic Violence Situation __Streets __Hospital __Parents/Relatives (need notice) __Emergency Shelter __Psychiatric Facility __Friends (needs notice) __Transitional Housing __Jail/prison __Rental Housing __Couch Hopping __Foster care __Other______

Current employment: School status: __ Full-Time employment __ Graduated High School __ Part-Time employment __ Attending High School (grade level completed)___ __ Not currently employed __ Complete d GED Program

__ Disabled/ unable to work ______Monthly Income Attending GED Program Receiving Public Assistance Y or N __ Dropped out of school __ Attending College __ In alternative school (grade level completed)___ Other Household members: Name ______M F Age ______Race______(Include Children) Name ______M F Age ______Race______Name ______M F Age ______Race______SAIL graduate? Y/N Are you alcohol/drug free? Y/N If no, are you in treatment? Y/N Would you live with a roommate?______

Social Worker:______Phone:______Probation Officer:______Phone:______

Tennessen Warning Notice Your name, date of birth, and (list other information we need for the study) are considered private data. With your consent, that information will be shared with the Minnesota Housing Finance Agency, and other funders which will use it to access records regarding your past participation in various assistance programs to determine the effectiveness of a homeless prevention program. The information may also be provided to others when authorized by state statute or federal law. You may refuse to allow us to use that information for the purpose I just described without affecting your eligibility for any programs. May we use your name, date of birth, and (the other information we need for the study) for the purpose I described?

Youth approved the use ____ Youth did not approve the use ___

Notes:

RESOURCES GIVEN:

____ Housing ____ Employment ____ Mental Health ____ Chemical Dependency ____ Education ____ Medical ____ Food Shelf ____ County Services (SNAP/CASH) ____ Emergency Services (CC) ____ Financial Services ____ Shelters ____ Parenting ____ Transportation ____ Other: Explain ______