NETMIS PROGRAM LOG INTAKE/EXIT INFO

Interface/Family Action Program

Participant Name:

/

NETMIS #:

Intake Date: /

Intake Time:

/

Intake Staff:

Site:IYPC___IYPE___IYPNW___FAC___FAE___FANW___

/

Service Status: a. full admit

/ Screening Date:
CINS/FINS Intake Assessment Completed: __yes __no / Completed Date: / Staff:
Assigned Counselor: / CINS Court Order: __yes _X no / Ordered Date:
Needs Assessment Initiated: _X yes __no / Date Initiated: / Date of Non Res Next Appt.:
Comp. Suicide Assessment Completed? _yes __no Completed Date ______Name of Suicide Tool: Suicide Questions
Participant from a Military Family? ___yes ___no / Completed Intake: ___yes ___no
Discharge Date: / Discharge Time: / Exit Staff:
12-hr follow-up needed: Yes ____ No ____ Expected arrival: Date: _____/_____/_____Time: ______:______am/pm
12-hr follow-up confirmation: Date _____/_____/_____Time: ______:______am/pm Staff:
Discharge Status (Check One):
  1. __ Services Completed, After Care planned
  2. __ Not applicable
  3. __ Services Completed, Referral Made
  4. __ Family Voluntarily Withdrew *
  5. __ Service Incomplete, Youth Expelled by Provider *
/
  1. __ Service Incomplete, Youth Ran Away
  2. __ Services Completed, Youth Removed Protective Agency
  3. __ Service Incomplete, Adjudicated *
  4. __ Other *
[* Consult with supervisor prior to these responses]
Living Situation at Discharge (Check One):
  1. __ Parent/Guardian Home
  2. __ Other Parent’s home
  3. __ Relative’s home
  4. __ Friend’s home
  5. __ Other adult’s home
  6. __ Foster home
  7. __ Group home
  8. __ Transitional Living Program
  9. __ Independent Living Program
/
  1. __ Job Corps
  2. __ Basic Center (Interface)
  3. __ Homeless Family Center
  4. __ Living Independently
  5. __ On the Run
  6. __ On the Street
  7. __ In Squat
  8. __ Educational Institute
  9. __ Drug Treatment Center
/
  1. __ Residential Treatment
  2. __ Mental Hospital
  3. __ Correctional Inst/Detention
  4. __ Other Institution
  5. __ Other temporary shelter
  6. __ Military
  7. __ Other
  8. __ Do Not Know

Employment Status of the Youth at Discharge (Check One):
  1. __ Full Time (over 35 hours)
  2. __ Part Time
  3. __ Seasonal/Sporadic
/
  1. __ Not Employed, Looking for work
  2. __ Not Employed, in school
  3. __ Not Employed, unable to work
/
  1. __ Not Employed, not looking
  2. __ Do Not Know/Other

School Program at Discharge (Check One):
  1. __ Elem./ Middle/ High School
  2. __ GED
  3. __ Vocational
/
  1. __ Special Education
  2. __ Alternative/ Homebound Program
  3. __ Post-Secondary
/
  1. __ College
  2. __ Not applicable
  3. __ Do Not Know

School Status at Discharge (Check One):
  1. __ Attending School Regularly
  2. __ Graduated High School
  3. __ Completed GED
/
  1. __ Attending School Irregularly/Truant
  2. __ Dropped Out
  3. __ Suspended
/
  1. __ Expelled
  2. __ School not in session
  3. __ Do Not Know

Agency Provided Exit Care and Aftercare at Discharge (select all that apply):
__ Exit Counseling (resources/destination)
__ Follow-up services or referrals / __ Follow-up meeting or scheduled contact __ Exit “Package” / __ Other
__ Youth refused aftercare/exit care services
Youth/ Family Referred to, at Discharge ( select all that apply):
__ HUD Sec 8/ or other permanent housing
__ TANF/ other welfare/ non-disability income
maint.
__ SSI or disability assistance
__ Medicaid
__ S-CHIP
__ Food Stamps or other non WIC nutrition / __ WIC
__ Childcare (Non TANF)
__ Kid Care
__ Child Support
__ Unemployment insurance
__ Workforce development services
__ Mentoring prog. other than RHY(CDS)agency / __ Mentoring program by RHY agency
__ National Service
__ Non residential SA treatment or MH Program
__ Other public federal, state or local program
__ Private non-profit charity/ foundation
__ Individual Dev/ Account

Rev. 2/06, 8/09, 8/13, 1/14, 9/14, 4/15 F-PR-1096