Teen Parent Connection Application

Teen Parent Connection Referral Form

Thank you for your interest in TPC! Please complete the form below in full.

If support is also needed for identifying a safe and stable placement, please complete a Network referral as well by clicking here.

Name of Refering Agency or Referral Source: *

Agency Type: *

Name of Person Referring: *

Position Title: *

Phone Number: *

Email Address: *

Name of Teen: *

Preferred Name, if applicable:

Teen's Email:

Teen's Phone Number:

DOB: *

Age: *

SSN: *

Name of Foster Parent/Guardians, or Group Home contact person: *

Current Placement Type *

Name of Placement:

Home Phone Number: *

Work Phone Number: *

Address of Teen's Residence: *

City: *

Zipcode: *

County of Residence: *

Legal County: *

Primary Language: *

Secondary Language:

Race/Ethnicity *

Gender: *

Name of DFCS Case Manager: *

Email Address: *

Work Phone Number: *

If applicable, please list the name, relationship, and contact information for any other supports involved:

Teen's Pregnancy Status *

Pregnant

Parenting

Pregnant and Parenting

Due Date OR Child's Birth Date: *

# of Living Children *

Legal Status of Teen: *

DFCS Custody

DJJ Custody

EYS

Emanicipated

Martial Status: *

Sexual Orientation

If not married, if the teen parent in a dating relationship?

Yes

No

Unknown

Child(s) First and Last Name

+-

Child(s) Date of Birth

+-

Child(s) Gender

+-

Child(s) Race

+-

Child(s) Residence

Teen Parent

Maternal Relative

Paternal Relative

Foster Home

Child(s) Legal Status

State Custody

Parental Custody

Other Guardianship

Unknown

If teen does not have physical custody of child(ren), is there a reunification plan in place? *

Yes

No

Unknown

If no, are there plans to develop a plan and if so, when?

Has the teen retained their parental rights? *

Yes

No

If no, date of termination:

Is the teen interested in regaining custody and/or keeping parental rights? *

Yes

No

If parenting, has teen been investigated due to child abuse or neglect report?

Yes

No

If so, was the report substantiated?

Yes

No

Date of Substantiation: *

Is the case currently open? *

Yes

No

Why is the teen being referred for TPC services? *

Needs may include:

Parenting skills

Legal support

Job skills

Financial literacy

Has the teen been involved in any criminal activity? *

Yes

No

Unknown

Was the teen adjudicated?

Yes

No

Unknown

Is the teen currently under probation?

Yes

No

Unknown

If yes, please describe: *

Does the teen have a history of substance abuse? *

Yes

No

Unknown

Does the teen currently use tobacco? *

Yes

No

Unknown

Does the teen have a history of mental health concerns? *

Yes

No

Unknown

Is the teen currently taking any prescription medications? *

Yes

No

Unknown

Has the teen ever run away from home or any placement? *

Yes

No

Unknown

If yes to any, please describe:

Teen's School Status *

If in school, last grade completed:

Does the teen have an educational goal? *

Yes

No

Unknown

If so, describe:

Employment Status *

If unemployed, is the teen looking for work?

Does the teen have a bank account? *

Yes

No

Unknown

If so, is it an IDA?

Yes

No

Unknown

Does the teen have a valid driver's license? *

Yes

No

Unknown

If not, does the teen have a learner's permit?

Yes

No

Unknown

Has the teen had any driving violations? What for? *

Please review the list of optional uploads below, and add any documents that are applicable/available for the young person being referred.

Universal Application

Casey Life Skills Assessment

CCFA

Psychological Evaluation

Current Case Plan

Child's Case Plan

Is there anything else relevant not already listed? *