County of San Diego • Health and Human Services Agency • Child Welfare Services
Transitional Youth Housing Program (TYH) REFERRAL FORM
ILS Transitional Housing, 7947 Mission Center Court, San Diego, CA 92108
Phone: (866) ILS-INFO 866 457-4636; Fax: (619) 767-5221
Send Referral TO:
Today’s DATE:
DATE HOUSING WILL BE NEEDED:
Applicant’s FULL Name:
First
Gender:
Middle
Maiden Last
DOB:
Married Last
Suffix
A.K.A./Alias Name
Soc. Sec. Number:
Email:
Current Residence: Please select one of the drop-down options
Name of GH/FFA, or describe Other
Current Address:
Phone:
Street
City
Zip Code
Case Carrying County SW/PO:
Name
Phone
Name
Phone
ILS County Social Worker:
ILS Contract Case Manager:
Name
Education:
Agency
Please select one
Phone
completed on
Currently Enrolled In: Please select one
# of Units Earned:
Name of School/Program:
Goal/Educational Plan:
Employment Status:
Please select one
Name of Current Employer
# of Hrs/Wk
Goal/Career Plan:
Pregnant/Parenting:
Currently Pregnant
Marital Status:
Please select one
Transportation
Driver’s License/Permit
Parent of #
Yes
Primary Language:
children
Please select one
No
Secondary Language:
Desired Residence: In what Region of the County does Applicant want to live (number from 1 to 7 in order of preference)?
No Preference
N Coastal
N Inland
N Central
Central
East
South
Any Disabilities/Special Needs Accommodations:
Is there anything else you would like us to know?
Referral Made BY:
Name
Title, Agency
COUNTY USE ONLY: Eligibility Verified:
Referral sent to (circle):
Anticipated
Date
Staff
Casa NAI Second Chance SBCS
Date
Yes, eligible.
CWS
Probation
Phone
Actual Juris Term:
Date
Previous Housing Program # days used:
Provider/County:
Last Placement/Comments:
Confirmed youth placed in court-ordered, out-of-home placement up to age 18 yrs or older
SD County Jurisdiction
Confirmed former foster youth returned to family or guardianship established after 16 th birthday
No, not eligible. Reason:
TYH Referral Form
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04/15/13