LifeStrengths Nomination

LifeStrengths Youth Nomination Form

If you are a nominating agency or partner, please fill out the form below to nominate a youth to be coached in LifeStrengths. If your agency is not listed, please contact nominations@ipourlife.org for assistance.
Youth's Full Name*
Nomination Date*

MonthDayYear
Nominator Contact Name*
Nominator Contact Phone Number*
Nominator Email address*
Agency Nominating This Youth*
Previously or Currently in State's Custody/Care*

Children's DivisionDivision of Youth ServicesN/ANever Been In Care
What is the case management county? *
Does the youth fall under the requirements for VOCA (Victims of Crimes Act)?*

YesNo
Nearest City to Youth*
Projected Age Out Date of State Care

MonthDayYear
Youth's Address
Youth's Phone Number
Youth's Date of Birth*

MonthDayYear
Youth's Age*
Gender*

FemaleMale
Race/Ethnicity *

WhiteBlackAmerican Indian/Native AmericanAsian/Pacific IslanderHispanicUnknownOther
Highest Level of Education Completed*

GED/HiSET AttainedHigh School Diploma AttainedCollege Degree AttainedVocational/Technical Degree AttainedCertification/License AttainedHigh School Drop OutCurrent High School/HiSET/GED Student
If still in school what grade

8th Grade9th Grade10th Grade11th Grade12th Grade
Current Education Status*

Not EnrolledEnrolled in High SchoolEnrolled in HiSET/GEDEnrolled in CollegeEnrolled in Vocational/Technical Program
If dropped out, last grade completed
Employment*

Full-time jobPart-time jobMore than one jobUnemployedNot Employed/In School
If employed, job location
Past Criminal History

YesNoUnknown
If yes, what past criminal history?
Benefits received (check all that apply)*

NoneMedicaidChafeeChild supportFood StampsSSDWICTANFSSISpousal supportVA Assistance
Living Status*

Foster HomeHomelessHomeless - Rapid RehousingLives with familyLives with friendsRentingTemporary housingTransitional housingResidential FacilityScattered SitesUnknown
History of Substance Abuse?*

YesNoUnknown
If yes, what substance abuse?
Are you aware of any special accommodations? This could range from cognitive concerns to a physical disability.*

YesNo
If yes, please explain.*
Does the Youth Have Existing Positive Relationships Not Staff or Counselors?*

No1 Positive Relationship2 Positive Relationships3 or More Positive Relationships
List any Positive Relationships
Should be Empty:

LifeStrengths Youth Nomination Form