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EPY Youth Data Form
Your Name
CLC Firm
- None -
1
2
3
4
5
Case Number
Gender
- None -
Male
Female
Non-binary
Decline to state
Race/Ethnicity
Check all that apply.
American Indian/Alaska Native
Asian
Black/African American/African
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White/Caucasian
Other
Client Declines to State
Client Does Not Know
Youth EPY Status
- None -
Pregnant
Parenting
Pregnant and Parenting
Has an EPY conference been scheduled or completed?
- None -
N/A – Client declined
No
Yes, referred
Yes, scheduled
Yes, completed/attended
Expecting Youth
Has the youth disclosed pregnancy to the attorney?
- None -
No
Yes
How far along in the pregnancy is the youth at the time of completing this form?
Client does not know
One month (week 1-6)
Two months (week 7-11)
Three months (week 12-16)
Four months (week 17-20)
Five months (week 21-24)
Six months (week 25-28)
Seven months (week 29-32)
Eight months (week 33-36)
Nine months (week 37+)
If yes (attorney notified), how far along in the pregnancy when the youth disclosed status?
Client does not know
One month (week 1-6)
Two months (week 7-11)
Three months (week 12-16)
Four months (week 17-20)
Five months (week 21-24)
Six months (week 25-28)
Seven months (week 29-32)
Eight months (week 33-36)
Nine months (week 37+)
Has the youth received counseling regarding pregnancy options?
- None -
No
Yes
Has the youth been referred to the Expecting and Parenting Payment Program (EPP)?
*
EPP provides $900 a month for the last three months of pregnancy
- Select -
Ineligible – Home of Parent
Ineligible – Youth over 21 years old/no longer foster youth
Ineligible – Away from care/not approved placement
No
Yes
Why is the youth not receiving EPP?
*
If referred to DCFS CSW for EPY, what agency prompted DCFS to complete the youth’s referral to the EPP payment?
- None -
N/A – Not Eligible
CLC
DCFS EPY Unit
Probation
NFP
Other
If referred, was the payment initiated, and did they receive the three months of eligible payments?
Has the youth been referred to a Nurse Family Partnership Program (NFP) or in-home visitation program?
Client declined
No
Yes
Parenting Youth
If parenting, is the youth receiving the Infant Supplement Payment?
Ineligible – Away from care/not approved placement
Ineligible – Home of Parent
Ineligible – Youth does not have custody of child(ren)
Ineligible – Youth over 21 years old/no longer foster youth
No
Yes
Other
Is the youth accessing the Parenting Support Payment ($200)?
No, youth not in SILP
No, youth does not have an adult mentor
No
Yes
Has the youth been referred to the Emergency Child Care Bridge Program?
No
No, does not qualify
Yes, but not interested or needed
Yes
Has the youth received reproductive health counseling from a certificated reproductive health specialist?
Check all that apply.
No
Yes, ACT Clinic
Yes, Certified Peer Advocate
Yes, Community Clinic or Health Care Provider
Yes, Planned Parenthood
Additional Questions
Is the youth receiving WIC?
- None -
N/A – Client declined
No
Yes
Is the youth using contraceptives/birth control?
N/A – Currently pregnant
No
Yes, birth control other than LARC
Yes, condoms
Yes, LARC (Long-Acting Reversible Contraception)
Notes
