Transition to Independence Process (TIP) Referral

450 Parkway Drive Suite 208 Broomall, PA 19008 Phone: 610-325-3131 Fax: 610-325-3137
Transition to Independence Process (TIP) Referral
Serving Transition Age Youth (ages 16-26) residing in Delaware County

*Please also include the young person's most recent Psychological Evaluation or document listing proof of Mental Health diagnosis along with this referral*
Referral Information
Referral Date

MonthDayYear
Date
Is the young person in agreement with a TIP referral being submitted on their behalf?

YesNo
Young Person’s Demographic Information
Chosen Name
Birth Name
Birth Date

MonthDayYear
Date
Medical Assistance #
Gender Identity
Pronouns
Social Security #
Race
Phone Number
Address
Email Address
example@example.com
Caregiver’s Contact Information
Name(s)
Relationship to the YP
Phone Number
Address
Email Address
example@example.com
Does the Young Person give permission for the TIP Program to contact this person to discuss the referral for TIP Services?

YesNo
Information about the Young Person
Current School Attending (if applicable)
Current School District Attending (if applicable)
Is the YP working?

Yes, Full TimeYes, Part-TimeNo
Is the YP experiencing housing instability?

YesNo
If yes, please explain
Mental Health History
Primary Mental Health Diagnosis (Include DSM V Code)
Secondary Mental Health Diagnosis (Include DSM V Code)
Additional Mental Health Diagnoses (Include DSM V Code)
Treatment History (check all that apply)

YP is currently placed in a Residential Treatment Facility or Inpatient Treatment Facility
If so, anticipated discharge date:

MonthDayYear
Date
Treatment History (check all that apply)

YP has had THREE (3) or more crisis visits either by walk-in or mobile crisis services in thelast two years.YP has had SIX (6) months or more of continuous mental health treatment (i.e., individualtherapy, group therapy and/ or medication management) in the last two years.YP has had SIX (6) months or more of mental health treatment provided by a primary care physician in the last two years.
Referral Source’s Information
Referral Source

Self-ReferralReferral by Natural SupportReferral by Formal Support
Affiliation with the Young Person
Referring Person’s Name
Referring Person’s Phone #
Does the young person want to participate in TIP?

YesNoNot Sure
Systems Involvement

Fill Out all that apply
Mental Health Treatment Involvement (Agency Name & Contact info)
Probation Involvement (POs Name & Contact)
Children & Youth Services Involvement (CYS Name & Contact)
Office of Intellectual Disabilities Involvement (OID Name & Contact)
Drug & Alcohol Treatment Involvement (Name & Contact)
To be answered by the Young Person:
Areas of support to be targeted during the delivery of TIP Services (check all that apply)

Self-Maintenance/Daily Living SkillsResiliency/Recovery PlanningIdentification of Community SupportsEducational/Vocational SupportSocial DevelopmentTransitional Planning/Independent LivingOther – Specify
What service goals to you wish to accomplish while receiving TIP Services?
Attestation and Signatures:
I understand submitting this referral does not guarantee enrollment of the young person into the TIP program. Upon review, the administrative team will contact the young person or designated caregiver to discuss eligibility.
Young Person's Signature

Clear
Date

MonthDayYear
Date
Referring Person’s Signature (if applicable)
Referring Person’s Signature (if applicable)

Clear
Date

MonthDayYear
Date
Please submit the completed TIP Referral to: Nikki Kline, MA-MT, TIP Program Director nkline@childandfamilyfocus.org

If you have any questions, please contact the TIP program at 610-325-3131
Should be Empty:

450 Parkway Drive Suite 208 Broomall, PA 19008 Phone: 610-325-3131 Fax: 610-325-3137

Transition to Independence Process (TIP) Referral

Referral Information

Young Person’s Demographic Information

Caregiver’s Contact Information

Information about the Young Person

Mental Health History

Referral Source’s Information

Systems Involvement

Attestation and Signatures: