Transitional Housing Placement Program (THPP) for NMD

INTAKE APPLICATION

108 W ALEXANER AVENUE MERDED, CA 95348 (209) 233-9024
Transitional Housing Placement Program (THPP) for NMD
(To be submitted by County Social Worker or Probation Officer or Placement Officer)

Submit application ONLINE

(Please complete and submit application online)
DATE*

MonthDayYear
Date
Youth’s Name*
Case Number #*
Cell #
E-mail address
example@example.com
Home Address*
City*
State*
Zip Code*
Zip Code*

Female MaleGender:
Age
EDUCATION*

10TH Grade11TH Grade12TH Grade
HSDGED
Name of School*
Major (if applicable)
Office #

Have you taken college preparatory classes? YesNo
If yes, list the classes
What are your colleges of choice?
1.
2.
2.
2.
What are your career/vocational goals?
PLACEMENT AGENCY NAME*
CSW/PO
Email
example@example.com
Cell #
Fax #
Regional Center consumers: Regional Center Name
Case Worker Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
CAREGIVER
Name
Relationship
Cell #
PERMANENT ADULT CONNECTION
Name
Relationship
Cell #
Address
State
Zip Code
OTHER EMERGENCY CONTACT NAME
Relationship
Cell #
Address
State
Zip Code
HEALTH FACILITY INFORMATION ADDRESS
Doctor's Name
Phone #
Fax #
List any Health Problems
Reason for last Doctor’s Appointment
Date of last annual medical exam/physical

MonthDayYear
Date
Do you have any allergies? YesNo
If yes, please explain
Medications: (Please list all over-the-counter and prescription medication, including psychotropic medication you are currently taking)
Dentist Clinic Address
Dentist Name
Office Phone #
Fax #
Cell #
Date of last dental exam

MonthDayYear
Date
Psychiatrist Clinic Address
Psychiatrist Name
Office Phone #
Cell #
Fax #
Therapist/Counselor Office Address
Therapist/Counselor Name
Phone #
Fax #
EMPLOYMENT INFORMATION

ARE YOU CURRENTLY EMPLOYED? YesNo
How long have you been employed?
Name of company
Address
State
Zip Code
Job Position
Work schedule (hours/Days)
Supervisor’s name
Earnings per week
Earnings per week

Previous work/volunteer experience YesNo
Name of Company
Dates

MonthDayYear
Date
Job/Volunteer Position
YOUTH’S PERSONAL STATEMENT
(Please Complete or Attach Participant's Personal Statement)
Tell us about yourself. For example, what do you enjoy doing in your free time? What are your plans for the future? Why do you want to participate in the Transitional Housing Placement Program? What are your employment goals? What are your educational and/or vocational (trade) goals?
Tell us about the participant
Date

MonthDayYear
Date
Referral and Application approved by CSW/DPO

YesNo
Risk Assessment Questionnaire
CSW/ PO or Placement Officer Signature*

Clear
Application approved by ILP Transition Coordinator

YesNo
ILP Coordinator if applicable

Clear
Date

MonthDayYear

Hour MinutesAM/PM Option
ATTENTION
1.All required documents must accompany the THPP Application to expedite the assessment

2.Please delete reference to siblings in report(s), per WIC 827
THPP Required Documents Prior to Interview
THPP Required Documents Prior to Final Acceptance

1. Original THPP Application County Social Worker or Probation Officer. To submit Personal Statement, Youth to complete personal statement below.2. Current Psychological Evaluation and/or significant psychological information regarding the youth’s mental health County Social Worker or Probation Officer to submit.3. Current Status Review Court Report, Transitional Independent Living Plan and Case Plan/Case. Plan Update County Social Worker or Probation Officer to submit.4.Current Individualized Education Plan IEP or significant information regarding the youth’s education plan County Social Worker or Probation Officer to submit.5. Current transcript, please include results of California High School Exit Exams, General Education Degree (GED) letter of verification, copy of high school diploma or GED if available. Youth to submit.6. Current Quarterly Report and Needs and Services Plan if not included in quarterly report or letter from placement, relative caregiver or foster care provider. Letter includes adjustment to placement, chores, school, behavior and interaction with adult and peers County Social Worker or Probation Officer to submit.7. Current Court-Ordered Psychotropic Medication Authorization Form County Social Worker or Probation Officer to submit, IF YOUTH IS TAKING MEDS.8. Letter of approval for youth to be assessed for the THPP. County Social Worker to submit if applicable.9. Probation Officer. To submit Copy of Social Security Card, California ID/DL, Birth Certificate and Independent Living Program ILP Certificate or current referral for ILP classes County Social Worker or Probation Officer to submit.10. School Status Report/Graduation Check from the school counselor on letterhead outlining the Youth’s anticipated graduation date, how many credits earned, the number of credits required to graduate, and name of courses needed to satisfy the graduation requirements Youth to submit11. Medical, Dental. CSW to submit.12.Court Ordered visitation plan- Please list all court-ordered, monitored or unmonitored, weekly or overnight visits. Including name, relationship, number of visits per week, and contact information County Social Worker or Probation Officer to submit.
You Can Upload Requested Documents If Available

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INTAKE APPLICATION

Transitional Housing Placement Program (THPP) for NMD

CAREGIVER

PERMANENT ADULT CONNECTION

YOUTH’S PERSONAL STATEMENT

(Please Complete or Attach Participant's Personal Statement)

ATTENTION

THPP Required Documents Prior to Interview