Referral Form
PATHS is a Housing First program for young adults between the ages of 17-21 who have experience in the child welfare system and are without housing or at risk of being without housing. PATHS serves the following counties: Adams, Forest, Langlade, Lincoln, Marathon, Portage, Oneida, Vilas, and Wood.
Basic Information
Youth's Name (First, Middle Initial, Last)
*
Youth's Pronouns
*
He/him/his
She/her/hers
They/them/theirs
Youth's Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth's County of Residence
*
Youth's Primary Phone Number
Youth's Email Address
Does this youth have experience in the child welfare system?
Yes
No
Unknown
If yes, what is this youth's experience in the child welfare system?
Name of Individual Completing Referral
*
Individual Completing Referral's Job Title & Organization
*
Individual Completing Referral's Email Address
*
Housing
Is this youth currently in a safe, permanent housing situation?
Yes
No
Unknown
Is this youth homeless or at-risk of being homeless?
Yes
No
If yes, please explain this youth's current housing situation.
Is this youth able to live independently on their own?
Yes
No
Documents
Does this youth have the following documents? Check all that apply.
Birth certificate
Driver's license or state ID
Social Security card
Medical card
Health
Does this youth have health insurance?
Yes
No
Unknown
If yes, what insurance?
Does this youth have a primary care provider?
Yes
No
Unknown
Does this youth have a diagnosed mental health condition?
Yes
No
Unknown
Legal
Does this youth have any pending charges or past convictions?
Yes
No
Unknown
If yes, what are the pending charges or past convictions?
Is this youth on probation or parole?
Yes
No
Unknown
If yes, who is this youth's probation officer?
Education
Is this youth enrolled in school?
Yes
No
Unknown
If yes, what school does this youth attend?
If not in school, is this youth interested in any education or training programs?
Yes
No
Unknown
If yes, what education or training programs is this youth interested in?
Employment & Income
Is this youth working?
Yes
No
Unknown
If yes, please describe this youth's job details.
Does this youth have other source(s) of income? Check all that apply.
Social Security
Tribal benefits
Other
Is this youth enrolled in other employment programs? Check all that apply.
FSET
DVR
WIOA
Other
Transportation
Does this youth have their driver's license?
Yes
No
Unknown
If yes, does this youth have a vehicle available to use for transportation needs?
Yes
No
Does this youth have other reliable transportation? Check all that apply.
Family
Friends
Public transportation (bus or taxi)
Connections
Does this youth have supportive individual(s) in their life?
Yes
No
Unknown
If yes, who is that person/people?
Is that person/people available during times of crisis?
Yes
No
Unknown
Safety
Are there any safety concerns for this youth or staff?
Yes
No
Unknown
If yes, please describe these safety concerns.
Please list any factors that may trigger this youth and should be limited/avoided when working with them.
Other
Please provide other relevant information that would be helpful when working with this youth.
Submit
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