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Exit ILP Questionnaire
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
*
3.
DOB
(Required.)
*
4.
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
21
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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
*
9.
Does the Youth have certified birth certificate?
(Required.)
Yes
No
*
10.
Does the youth have an original social security card?
(Required.)
Yes
No
*
11.
Does the youth have a State Identification Card?
(Required.)
Yes
No
*
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
Completed: 2/4 College Program
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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
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20.
Is youth receiving SSI/SSDI?
(Required.)
Yes
No
unknown
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21.
Was the youth charged or convicted of a crime while in the program?
(Required.)
Yes
No
*
22.
Youth housing plan upon exit:
(Required.)
Unknown
Housing Insecure (Couch Surfing/Homeless, etc.)
Roommate (family, etc)
Own Housing
Other (please specify)
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23.
Housing upon exit:
(Required.)
Subsidized (Project Life, FUP, FYI, SCL, etc.)
Unsubsidized (rent/mortgage not subsidized by another program)
*
24.
Reason for exit from program:
(Required.)
Tranferring to another scattered site independent living program
Transitioning to more restrictive placement (foster home, supervised ILP)
Planned/Aging Out
Agency submitted notice to end placement
DCBS terminated commitment
Youth voluntarily ended commitment
*
25.
Did youth have a pet while in the program?
(Required.)
Yes
No
*
26.
Did youth have one of the following while in the program?
(Required.)
Service Animal
Emotional Support Animal
No