1.First Name

2.Last Name

3.DOB

4.Age

18 1/2

19

20

21

22

5.Gender

Born male/ Identify male

Born female/ Identify female

Do not identify with gender assigned at birth/ Gender fluid

6.Had the youth at any point extended their commitment to DCBS past their 18th birthday?

Yes

No

7.Housing status before entry into Project Life:

Homeless/Couch Surfing

DCBS Custody (Non ILP Placement)

DCBS ( Independent Living Program)

Other (please specify)

8.Type of Project Life Housing:

Single Unit

Roommate

Room Rental

Dorm/College Housing

9.Does the youth have a certified birth certificate?

Yes

No

10.Does the youth have an original social security card?

Yes

No

11.Does the youth have a State Identification Card?

Yes

No

12.Does the youth have:

A full Driver's License

Learner's Permit or Intermediate License

Neither

13.Does the youth own a vehicle?

Yes

No

14.Has the youth ever been charged or convicted of a crime?

Yes

No

15.Highest level of high school education the youth has completed?

9th

10th

11th

High School Diploma

Diploma equivalency (GED)

16.Has the youth enrolled in/completed a post-secondary educational program? (Select all that apply.)

No

Enrolled: short-term certificate

Completed: short-term certificate

Enrolled: college

Completed: 2/4 year college degree program

17.Is the youth parenting or currently expecting a child?

No

Expecting

1 Child

2 or More children

18.Is the youth receiving SSI/SSDI?

Yes

No

19.Is the youth currently employed?

No

Part -Time

Full - Time (at least 30 Hours Per Week)

20.What is the youth's hourly wage?

$7.50 - $10.00

$10.00 - $15.00

$15.00 - $20.00

More than $20.00