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Entry ILP Questionnaire
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
*
3.
DOB
(Required.)
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4.
Placement Agency Name
(Required.)
Brighton Center
DIOCESAN CATHOLIC CHILDRENS HOME
Boyshaven
HOPE HILL YOUTH SERVICES
KY Youth & Children's Foundation
Kentucky United Methodist Home
NECCO
Options To Success
SAFY
Sunrise
USPIRITUS BELLEWOOD CENTER
Other (please specify)
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5.
Age
(Required.)
18
19
20
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6.
Gender
(Required.)
Born male/ Identify male
Born female/ Identify female
Do not identify with gender assigned at birth/ Gender fluid
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7.
Does the youth have a signed, individualized Transitional Living Agreement?
(Required.)
Yes
No
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8.
Has the youth completed the LYFT Independent Living curriculum and earned the incentive?
(Required.)
Yes
No
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9.
Does the Youth have certified birth certificate?
(Required.)
Yes
No
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10.
Does the youth have an original social security card?
(Required.)
Yes
No
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11.
Does the youth have a state Identification Card?
(Required.)
Yes
No
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12.
Does the youth have:
(Required.)
A full driver's License
Learner's Permit or Intermediate license
Neither
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13.
Does the youth own a vehicle?
(Required.)
Yes
No
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14.
What is highest level of education the youth has completed?
(Required.)
9th
10th
11th
High School Diploma
Diploma equivalency (GED)
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15.
Has the youth enrolled in/completed a post-secondary educational program? (Select all that apply.)
(Required.)
No
Enrolled: Vocational Training Program
Completed: Vocational Training Program
Enrolled: College
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16.
Is the youth living in dorm/college housing?
(Required.)
Yes
No
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17.
Is the youth parenting or currently expecting a child?
(Required.)
No
Expecting
1 Child
2 or More children
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18.
Is the youth currently employed?
(Required.)
No
Part -Time
Full time (at least 30 Hours Per Week)
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19.
What is the youth’s hourly income?
(Required.)
$7.50 - $10.00
$10.00 - $15.00
$15.00 - $20.00
More than $20.00