yess4youth

Youth Information
DFCS Worker Information
Medical Information
Criminal System Involvement
Education & Employment
Support System & Additional Information

Full Name

Gender

Date of Birth

Age

Race

Social Security Number

Cell Phone Number

Email Address

Residing County

Legal County

Please select the documents that the youth or DFCS (check all that apply)
Original Birth Certificate Original Social Security Card State ID Driving Permit Driver's License Green Card/Resident VISA/Work Permit Others

Other Documents

Reason for seeking placement

DFCS Worker Name

DFCS Worker E-mail

DFCS Worker Cell Phone Number

Office Phone Number

DFCS Supervisor Name

E-mail Address

Cell Phone Number

Office Phone Number

Medical Insurance

Date of last physical Test

Date of last Dental Test

Date of last psychological Test

Allergies

Mental Health Diagnosis

Are you currently on medications (prescribed or over the counter)?

Medications (List primary psychiatric first)

Have you been involved in the criminal justice system in the past 3 years?

Are you on probation?

Please provide a summary of issues/charges:

Is the youth enrolled in school?

If, yes, name of school:

Educational Level (Last grade completed)

Current Educational Status

Does the youth have an IEP?

Is the youth currently employed?

Name of Employer

Do you have an Individual Development Account (IDA)?

Does the youth have a support system?

Please list the name and relationship/role of the people in youth’s support system:

Have you ever used / abused substances?

Type of Substance (s) Used