Youth’s Information

• Preferred Name (the name they wish to be called by)
• Legal Name
• Other nicknames or name pronunciation guide (OPTIONAL)
• Date of Birth
• Gender
• Preferred Pronoun (OPTIONAL)
• Race/Ethnicity
• Legal Status within the foster care system
  • If the youth is under Tribal Jurisdiction, indicate the tribe the youth is affiliated or associated with.
• Placement
• If Educational Advocacy and/or Graduation Success is requested:
  • In the past 12 months, how many times has this youth changed their primary living arrangement or home placement since entering foster care?
  • In the most recent school year, how many times has this youth transferred schools?
• Does the youth identify as a Native American?
  • If checked, indicate the tribe the youth is affiliated or associated with.
• Permanency Plan (OPTIONAL)
• Disability Status (Yes, No, or Unknown)
  • If ‘Yes’ AND Educational Advocacy requested, please list the youth’s disability or disabilities.
• Immigration Status (Yes, No, or Unknown)
• ESL/ELL Status (Yes, No, or Unknown)
  • If ‘Yes’, please list the youth’s first or primary language (if not English).

School Information

• Current Enrollment Status
• School Grade (if applicable)
  • Post-secondary grade level if youth is attending college or university.
• Educational Placement Program (e.g., General Ed, Special Ed (IEP), 504, etc. ) (if applicable)
• School District (if applicable)
• School Currently Attending (if applicable)

Parent/Caregiver Information (for youth not in an Independent Living placement)

• Parent or Caregiver’s Name
• Phone Number
• Other Phone Number (OPTIONAL)
• Email Address
• Physical or Mailing Address
• Is the caregiver’s primary or native language NOT English?
  • If ‘Yes’, please note the caregiver’s native language or other languages they may speak.

Youth Contact Information (For youth in an Independent Living placement)

• Phone Number
• Other Phone Number (OPTIONAL)
• Email Address
• Physical or Mailing Address

Other Information (OPTIONAL)

• Other Connections (e.g., CASA/GAL, Attorney, etc.) and their contact information.

Social Worker Information

• DCYF, Tribal, or Federal Foster Care Social Worker’s Name.
• Social Worker’s Phone Number
• Social Worker’s Email Address
• For DCYF Social Workers: the DCYF Office the Social Worker is based out of.

Educational Advocacy

For Educational Advocacy referrals, please have the following information:

• The current/immediate educational need(s) of the youth (school services, academic progress, discipline, attendance, and/or enrollment)
• Any important upcoming meetings (e.g., WISE/DRS, IEP/504, discipline, etc.) and the date(s) of the meetings.
• Any supporting documents that the Advocate may need such as current IEPs or other school records.
• A summary of the youth’s current educational issues or barriers.

Launch Success

For Launch Success referrals, please have the following information:

• The current/immediate need(s) of the youth (post secondary education, housing, employment, basic needs/resource referrals, and/or life skills)
• Any supporting documents that the Launch Success Coach may need, such as the participant’s Graduation Success Transition Checklist.
• A summary of the youth’s current goals.
• A summary of the youth’s current needs.