YBL Entry Form

YBL: Entry Form: Case Management Assessment

This form is for ALL participants of any YouthBuild affiliate program. Please read all of the questions and guidelines carefully, taking time to answer fully. Note that some questions will have an "ex:" (example) answer to help guide you. If you need further assistance in completing the form, please ask a staff member.
Case Management
Name:*

First NameMiddle NameLast Name
Assigned Case Manager Name*
Ask if you don't have one yet or don't know name.
Program Start Date*

MonthDayYear
Date
Check ALL that apply. I am a member of:*

YouthBuild Louisville TrainingYHDP HousingUrban Conservation Corps
Birth Date*

MonthDayYear
Age*
Your age today
Phone Number:*

Area CodePhone Number
E-mail Address:*
Your Email Address
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Number: Family, Friend, Work

Area CodePhone Number
Name of Family, Friend, Work

First NameLast Name
Race*

Hawaiian Native or other Pacific IslanderAmerican Indian or Alaskan HawaiianAfrican AmericanCaucasianAsianOther
Do you have a diagnosed disability?*

NonePhysical DisabilityVisual ImpairmentHearing ImpairmentSpeech / Language ImpairmentIntellectual DisabilitySpecific Learning DisabilityAutism Spectrum DisorderOther
Do you have any of the following conditions?*

HIV/AIDSSubstance Abuse IssueAlcohol Abuse IssuePrefer not to disclose at this time.Other
Gender*

MaleFemaleTransgender (M-F)Transgender (F-M)Gender NonconformingOther
Do you identify as LBGTQ?*

YesNo
Participant Type*

Current or Former Youth in Foster CareReferred by Guidance CounselorChild of Incarcerated ParentLow-Income FamilyYouth OffenderAdult OffenderMigrant YouthOther
Criminal Justice Information:
Received Pre-Release Services*

YesNo
Pre-Release Contract*

YesNo
Referral Source*
Mandated Enrollment*

YesNo
Alternative Sentence*

YesNo
Probation/ Parole*

YesNo
Date of Most Recent Probation Start Date

MonthDayYear
Date of Most Recent Probation End Date

MonthDayYear
Date of Most Recent Contact with Probation/Parole Officer

MonthDayYear
Type of Contact with Probation/ Parole Officer*

Email or Written ReportIn PersonPhoneOther
Name of Probation / Parole Officer

First NameLast Name
Phone Number of Officer

Area CodePhone Number
Assessment Information
Mental Toughness Completed*

YesNo
Basic Skill Deficient*

YesNo
TAP Participant*

YesNo
Co-Enrolled in WIOA (KYCC)*

YesNo
Are you a Veteran?*

YesNo
Registered for Selective Service? (NOTE: If you are Male and 18+ years old, you MUST be registered. We will help you complete this process.)*

YesNoNot Applicable (Female or under 18)
Have you been employed in the past 6 months?*

YesNo
Are you currently employed?*

YesNoEmployed, but on notice of Termination or Military Separation
Where are you employed? *
Ex: Wendy's, Kroger, Neil's Roofing
Occupation Title*
Ex: Cook, Cashier, Waitress
Weekly Hours at Enrollment*
ex: 30
Hourly Wage at Enrollment*
Ex: $9.75
Start Date of Employment*

MonthDayYear
Are you a U.S Citizen?*

YesNo
Authorized to work?*

YesNo
Are you registered to Vote?*

YesNo
Do you have the following:*

Driver's PermitDriver's LicenseNone of above
What source of transportation do you primarily use?*

WalkBicycleBus/ Public TransportationPersonal VehicleShared Ride / Friends & Family
Housing, Family, & Education
Housing Status at Enrollment*

Staying at someone's apartment, room, or house (Unstable)Staying at someone's apartment, room or house (Stable)Staying with Foster Guardian/ in Foster SystemRent/ Own Apartment, Room or houseHalfway house/ Transitional HouseResidential TreatmentLiving with FamilyHomelessOther
If you selected "YES" to homeless in above question, what was the approximate start date of homelessness?

MonthDayYear
Date
Have you been in any of the following institutions in the last 12 months?*

Foster Care/ Group HomeJailPrisonJuvenile Detention CenterPsychiatric HospitalSubstance Abuse Treatment or ClinicN/A (if does not apply.)
Completed Certifications. Select all you have obtained.

OSHASafe ServForkliftOther
Alcohol Abuse / Illegal Drug Use at Enrollment*

YesNo
Marital Status:*

SingleMarriedDomestic PartnerDivorcedSeparatedWidowed
Number of Children of Participant*
Ex: 2
Children living with Participant*
Ex: 2
Are you currently expecting a child?*

YesNo
Do you need childcare?*

YesNo
Other Dependents Living with Participants*
Ex: Relatives, Friends, Domestic Partners
Did you drop out of High School?*

YesNo
Highest School Grade Completed*
Ex: Relatives, Friends, Domestic Partners
How many years have you been out of school?*
Ex: Relatives, Friends, Domestic Partners
Did you have an educational credential?*

High School DiplomaHigh School Equivalency (GED) or (HiSet)Some CollegeNo Credential
If you enroll in post secondary education, will you be a 1st generation enrollee?*

YesNo
What is your initial desired post-secondary education credential ?*

Associates degreeBachelor's degreeGraduate/Professional degreeCertificateApprenticeship placementEmployment onlyUndeclaredUnknown
Is English your first language?*

YesNo
Additional Information
Household Income:*

None$1 - $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - and aboveOther
Public Assistance (Indicate ALL that apply as of today)*

Welfare for Single Adults or General AssistanceUnemployment InsuranceFood Stamps (SNAP)SSI, SSD, SSATANF/K-TAPPublic Assistance/ Non-TANFPublic HousingOther Government SourcesNo BenefitsOther
Medical Benefits (Indicate ALL that apply as of today)*

Private Health Insurance from Work or Family MemberMedicareMedicaidNoneOther
Mental Health Treatment*

YesNo
Are you a domestic violence survivor?*

YesNo
Child Support Obligation at Enrollment*
Number of Children you pay child support for.
Child Support Obligation - Amount*
How much $ per month is paid.
Public Assistance Prior to Enrollment (Check all that apply)*

Welfare for Single Adults or General AssistanceUnemployment InsuranceFood Stamps (SNAP)SSI, SSD, SSATANF/K-TAPPublic Assistance/ Non-TANFPublic HousingOther Government SourcesNo BenefitsOther
Amount of Public Assistance Prior to Enrollment (Check all that apply)*
$ per Month
Duration of Public Assistance Prior to Enrollment (Number of Months)*
# of Months
Medical Benefits Prior to Enrollment*

Private Health Insurance from Work or Family MemberMedicareMedicaidNoneOther
What additional services are you interested in? Select your top (3):*

MedicalCounseling/Mental Health/Support GroupsFinancial AidPublic AssistanceChild Care AssistanceLife Skills (Cooking, Organization)Money Management/ Financial WellnessClothingFood ResourcesRental AssistanceHousing AssistanceLegal Assistance
TABE Score

THIS SECTION REQUIRES STAFF ASSISTANCE TO COMPLETE
Reading
Reading Test Date

MonthDayYear
Date
Reading - Level

EMDA
Reading NRS*
Indicate # 1-5
Reading Scale Score*
If you have not taken, write N/A.
Mathematics
Math Test Date

MonthDayYear
Date
Math - Level

EMDA
Math NRS*
Indicate # 1-5
Math Scale Score*
If you have not taken, write N/A.
Learning Style
Cognitive / Receptive Learning Style*

AuditoryTactileVisual
Social Learning Style*

IndividualGroup
Expressive Learning Style*

WrittenOral
What does your career assessment say about you?
What is your Personality/ Behavior type, and what does it say about you?
Goals for My Success Plan

Write three goals for each question. Each goal should be a SMART Goal: Specific, Measurable, Achievable, Realistic and Time-Based.
Career Goal:
Ex: Nurse, Computer Engineer, Construction
Education Goal:
Ex: GED, High School Diploma, Associates Degree
Vocational Goal:
Ex: Nurse, Computer Engineer, Construction
AmeriCorps Goal:
Ex: Finish 450 Community Service Hours, 50 Hours Helping Homeless Youth, Earn Scholarship for College
Personal Goals:
Ex: Get a gym membership, eat healthier, learn how to meditate
Clothing Size

Please note you will be checked by a staff member for appropriate sizing.
Shirt Size
Jean Size
Ex: 32L, 40W
Shoe Size
Ex: 14 Men, 7 Women
Jacket Size
Recommend 1 size larger
Notes:
Height
Weight
Signature

I HEREBY CERTIFY THAT THE ANSWERS GIVEN BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER CERTIFY THAT I, THE UNDERSIGNED APPLICANT, HAVE PERSONALLY COMPLETED THIS APPLICATION. I VERIFY BY MY SIGNATURE THAT THE ABOVE ADDRESS IS MY CORRECT LIVING ADDRESS. I HEREBY AUTHORIZE YOUTHBUILD LOUISVILLE TO THOROUGHLY INVESTIGATE MY WORK RECORD, EDUCATION AND OTHER MATTERS RELATED TO MY SUITABILITY FOR ACCEPTANCE INTO THE PROGRAM. PLEASE ENTER YOUR INITIALS IN THE SPACE BELOW, INDICATING YOUR AGREEMENT TO THE TERMS LISTED ABOVE. YOUR INITIALS IN THE SPACE BELOW ACT AS YOUR SIGNATURE TO THIS DOCUMENT.
Your Initials*
Name of staff who assisted you:
Mike, Rae, Danyetta
Should be Empty:

YBL: Entry Form: Case Management Assessment

Case Management

Criminal Justice Information:

Assessment Information

Housing, Family, & Education

Additional Information

TABE Score

Reading

Mathematics

Learning Style

Goals for My Success Plan

Clothing Size

Signature