PROGRAM ELIGIBILITY & INTAKE ASSESSMENT

PROGRAM ELIGIBILITY & INTAKE ASSESSMENT

This form is used to determine eligibility and appropriateness for placement in a Transitional Living Program in accordance with applicable NCDHHS and federal RHY/TLP guidelines. Completion does not guarantee acceptance.
SECTION 1: REFERRAL SOURCE & REQUEST
Date of Referral

MonthDayYear
Date
Referral Type

Other
Referring Agency or Residing County of Applicant
Caseworker Name & Title
If none or not known, state N/A
Phone Number of Referral Source
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Please provide referral source's email address
Requested Placement Date

MonthDayYear
Date
Estimated Length of Stay
Primary Reason for Referral
Brief Summary (including immediate concerns, housing instability, or safety risks)
SECTION 2: YOUTH IDENTIFICATION & ELIGIBILITY SCREEN
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth
Gender at Birth
If you identify as a different gender than at birth or go by particular pronouns, please share that here:
Current Living Situation

Other
If other, please explain
Eligibility Indicators (Select all that apply)
If answering for someone else, is the young adult currently safe? If answering as yourself, please select yes or no.
If no, explain immediate safety concerns
Describe the primary need for placement
SECTION 3: PRESENTING NEEDS & PLACEMENT JUSTIFICATION

Describe the primary need for placement (last 30–90 days). Include behaviors, risks, instability, or system involvement.
What goals should placement address? Select all that apply.

Other
If other, please explain
SECTION 4: HOUSING, PLACEMENT, & LIVING HISTORY (LAST 2 YEARS)

List all known living situations, including formal placements and informal arrangements (e.g., staying with friends, family, couch surfing, unsheltered situations, shelters, foster care)
Do any of these apply to your history? Select all that apply.
Please provide history of housing, placement, & living history in last 2 years
SECTION 5: BEHAVIORAL HEALTH & RISK SCREENING
Mental Health History
If yes to diagnosed, please list below & if you recall who or what provider diagnosed you.
History of hospitalizations?
Risk Assessment - History of or Current - Select those that apply
If yes, dates and reasons
Trauma History (Trauma-Informed Summary)
(Avoid graphic detail; attach assessments if available)
SECTION 6: FUNCTIONAL ASSESSMENT
Independent Living Skills - Hygiene/Self-Care
Independent Living Skills - Medication Management
Independent Living Skills - Cooking/Nutrition
Independent Living Skills - Money Management
Independent Living Skills - Transportation Use
Education & Employment
SECTION 7: MEDICAL & MEDICATION
Primary Care Provider
Last Physical Exam

MonthDayYear
Date
Medical Conditions
Medical Conditions - Details
Current Medications
Please include medication name, dose, frequency, provider, & purpose
SECTION 8: FINANCIAL & BENEFITS STATUS
Financial & Benefits Status
SECTION 9: SUPPORT SYSTEM & PERMANENCY
Family/Support Contacts
Is reunification a goal?
Identified permanent connections?
SECTION 10: REQUIRED DOCUMENTATION TRACKING
Document Status: Consent to Care Placement
Document Status: Intake Referral Form
Document Status: Health Information Release
Has the youth been informed of the program expectations?
Is the youth willing to participate?
Youth Signature
Referring Party Name & Title
Referring Party Signature
Referring Party Date

MonthDayYear
Date
Should be Empty:

PROGRAM ELIGIBILITY & INTAKE ASSESSMENT

SECTION 1: REFERRAL SOURCE & REQUEST

SECTION 2: YOUTH IDENTIFICATION & ELIGIBILITY SCREEN

SECTION 3: PRESENTING NEEDS & PLACEMENT JUSTIFICATION

SECTION 4: HOUSING, PLACEMENT, & LIVING HISTORY (LAST 2 YEARS)

SECTION 5: BEHAVIORAL HEALTH & RISK SCREENING

SECTION 6: FUNCTIONAL ASSESSMENT

SECTION 7: MEDICAL & MEDICATION

SECTION 8: FINANCIAL & BENEFITS STATUS

SECTION 9: SUPPORT SYSTEM & PERMANENCY

SECTION 10: REQUIRED DOCUMENTATION TRACKING