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HPA Referral Form
CLC Firm
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- Select -
LA 1
LA 2
LA 3
LA 4
LA 5
SAC 1
SAC 2
Dependency Contact Information
Attorney Name
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Phone
Email
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Attorney Supervisor Name
Phone
Email
DCFS CSW Name
*
Phone
Email
*
DCFS SCSW Name
*
Phone
Email
*
Referral Information
Please provide the following information about the young person you are referring.
NMD No.
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First Name
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Last Name
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Birth Date
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Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Gender
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- Select -
Male
Female
Non-binary
Decline to state
Transgender Status
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- Select -
No
Yes
Decline to state
Preferred Pronouns
*
- Select -
he/him/his
she/her/hers
they/them/their
Race/Ethnicity
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Check all that apply.
Asian
Black/African American/African
Hispanic/Latino
Middle Eastern/North African
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White/Caucasian
Client Declines to State
Client Does Not Know
Other
Unknown
Accommodations Needed?
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None
Vision impairment
Hearing impairment
Mobility impairment
Learning disability
Decline to state
Is the client a regional center consumer?
- None -
No
Yes
Current Living Situation
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- Select -
Away from Care/AWOL
Homeless/Unhoused
Shelter
Substance Abuse Treatment Facility
Residential Treatment Center
Home with One Biological Parent
Home with Both Biological Parents
Home of Relative
Home with NREFM
Medical Hospital
Psychiatric Hospital
DDMI
DCFS Foster Home
FFA Foster Home
STRTP
STRTP - EPY
Juvenile Hall
Probation Suitable Placement
Probation Camp
Dorothy Kirby Center
Secure Treatment Facility (SYTF)
Regional Center Home
Transitional Housing
Supervised Independent Living (SILP)
NMD not in placement
NMD not in approved SILP
Jail
Other
Street Address
City
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State/Province
Zip Code
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Youth's Working Phone Number
*
Need and Characteristics
Which areas of advocacy does your client need assistance with?
*
Check all that apply.
Budgeting support
Landlord v. tenant education
Landlord v. tenant advocacy/referrals to outside agencies
Housing Financial assistance (1st/2nd month’s rent and/or security deposit) - can only be spent on youth being served by program
General housing stability counseling (walking youth through becoming a tenant and maintaining housing)
Risk of homelessness: considered at risk if they will lose primary residence within 30 days (e.g., domestic violence, intimate partner abuse, or a trafficker).
Emergency housing assistance: Client is unhoused and has no options for overnight housing at time of referral within 72 hours.
Post-21 (non-NMD) housing connection and preparation
Public Assistance Application/Information
Is this young person receiving any public benefits?
*
- Select -
No
Yes
To the best of your knowledge, check all the following documents that the young person already has:
Check all that apply.
Identification Card
Birth Certificate
Social Security Card
Credit Check
Other
Is this client an expecting and/or parenting youth?
- None -
No
Expecting
Parent
Expecting and Parent
Does this young person have an active or pending juvenile/criminal court case?
- None -
No
Yes
Is the youth currently on probation?
- None -
No
Yes
Have you introduced/discussed our CLC Housing Program with the NMD?
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- Select -
No
Yes
Additional CLC Information
Is there a companion case?
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- Select -
No
Yes
Name of Clients
Is there a conflict history?
*
- Select -
No
Yes
Conflict CLC Firms
CLCLA1
CLCLA2
CLCLA3
Other
Conflict Case Number
Explanation for Conflict
Any relationship (positive or negative) with another CLC client?
Please provide a short summary of your reason for referral and specify the best way to reach the youth.
*
Referral Outcome
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- Select -
Accept
Decline
Other
Indicate youth interest in the program (i.e., referral outcome)
