Juvenile Justice Enrollment Form (BENEFITS)

Juvenile Justice Enrollment Form (BENEFITS)
Welcome to the Family Navigator Juvenile Justice Program, where we support you during court cases, connect you to social services, and support you as you communicate with court staff. We help you navigate and better understand the juvenile justice system, so that you can be in the best position to support your child. Please complete all of the information below to enroll and get started!

***BEFORE YOU BEGIN, you will need a copy of all the documents below.***
Below, please upload a copy of your government-issued ID. *

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Below, please upload a Summary of Benefits (must show the child's name and your address). Other examples include verification that you receive cash, food Medicaid, or publicly-funded childcare assistance through Lucas County Job and Family Services. *

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Name*

First NameLast Name
Date*

MonthDayYear
Date
Do you or any of your family members participate in any of these Center of Hope Programs:*

Family NavigatorNurturing ParentsENGAGEELEVATE Afterschool ProgramNone
How did you hear about us?*

Internet (Google Search)Social MediaReferral
If you heard about a program from a referral, please list their name (otherwise, type "None")*
By signing below, I am acknowledging that the above information I provided is accurate.*

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Date*

MonthDayYear
Date
Client Goals and Case Plan
Name of Client*

First NameLast Name
Date of Case Plan*

MonthDayYear
Date
Are any of these barriers for you?*

FoodClothingTransportationUnemploymentChild Support/CustodyHealthEducationHearing Support/Attorney ReferralsCSEA/LCJC Paperwork HelpSupport at my child's schoolQuestions about my child's school or progress at schoolAccess to mental health servicesOther
What are your strengths?*
Goals/Action Steps (Please check the goals you'd like to complete)*

Job searchVolunteer work experienceJob sampling/Job shadowingOn-the-job trainingEmployment counselingRegistration with local job serviceJob readinessHigh school diplomaGEDESL (English as a second language)Adult vocational trainingLiteracy improvementHigher educationLife skills activitiesParenting skillsChildcare assistanceChild supportSubstance abuse treatmentCounselingDriver's license reinstamentDental/health careSSA ApplicationMedical reportDecision lettersLegal AssistanceCare for child under age 6Other
Which date do you think you'd have the goals completed (with our help):*

MonthDayYear
Date
Please check the box after you have read and understand:*

I understand that the purpose of this plan is to meet the identified goals through specific steps and I am required to follow the steps developed. I understand that I must participate in work activities and/or other activities and referrals developed in this plan. Failure to follow through may constitute removal from the program. I also understand that if there are any changes to be made that I will contact case worker in a timely manner to ensure my success in this program.
Please check the box after you have read and understand:*

I understand that the purpose of the case plan is to follow through with goals listed (i.e., accessing other resource programs, keeping medical apps, et.). Failure to follow through with the steps identified in the case plan may constitute suspension from the General Assistance Program.
Signature*

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Date*

MonthDayYear
Date
I, Full Name*, grant permission to Center of Hope Family Services, Inc. and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.

I hereby release Center of Hope Family Services, Inc. and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

I acknowledge that I am over the age of 18 and the legal guardian of the child.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

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Improving the life outcomes of adults, children, and families in urban settings.

419.861.4400 | 5461 Southwyck Blvd. Toledo, OH 43614 | www.cohfs.org
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