Form Tilp 1 - Transitional Independent Living Plan & Agreement
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3State of California – Health and Human Services Agency
California Department of Social Services
TRANSITIONAL INDEPENDENT LIVING PLAN & AGREEMENT
Youth: _____________________________ Date of Birth: __________ Age: ____ Ethnicity: _____________
Address: ________________________________________________________________________________
Instructions To Youth: The purpose of this agreement is to capture the goals you are agreeing to achieve
over the next 6 months. It is a good organizing tool to help you stay focused and keep track of your progress
toward accomplishing each goal. Your Social Worker/Probation Officer and caregiver will also have copies of
this agreement and will help you achieve your goals.
Instructions to Caregiver: You are agreeing to assist the youth in the development of their ILP goals and to
support the youth in completing the activities.
Instructions to Social Worker/Probation Officer: You are agreeing to assist the youth and the caregiver in
completing this form, and develop Planned Services that will assist the youth in meeting his/her goals.
Document the Planned Services and Delivered Services in CWS/CMS. Probation officers: use manual
documentation procedures.
Service goals and activities to be addressed in the plan:
Goals are individualized based on your assessment and may include examples such as:
• develop a life-long connection to a supportive adult
• graduate from high school
• obtain a part-time job
• invest savings from part-time job
• develop community connections
• obtain a scholarship to attend college
• develop competency in the life skill of ____________________________________________________
Activities are individualized to help meet a specific goal. Example – if high school graduation is a goal, the
youth directed activity might be to attend classes regularly with no tardies for the next 6 months.
For youth participating in ILP services, activities are reportable as ILP Delivered Services in CMS. The social
worker shall select from one or more of the following ILP Service Types that an individualized completed
activity fits in:
• Received ILP Needs Assessment
• ILP Room and Board Financial Assistance
• ILP Mentoring
• ILP Transitional Housing, THP, THP Plus
• ILP Education
• ILP Home Management
• ILP Education Post Secondary
• ILP Time Management
• ILP Education Financial Assistance
• ILP Parenting Skills
• ILP Career/Job Guidance
• ILP Interpersonal/Social Skills
• ILP Employment/Vocational Training
• ILP Financial Assistance Other
• ILP Money Management
• ILP Transportation
• ILP Consumer Skills
• ILP Other (Stipends/Incentives)
• ILP Health Care
I understand that if I am employed as part of this plan, my earned income will be disregarded, as
the purpose of my employment is to gain knowledge of needed work skills, habits and
responsibilities to maintain employment. (WIC 11008.15)
I understand that I can retain cash savings up to $10,000 under this plan in an insured savings
account and any withdrawal requires the written approval of my social worker/probation officer and
must be used for purposes directly related to my transitional goals. (WIC 11155.5)
I understand that I will receive assistance to obtain my personal documents and information about
financial aid for postsecondary education/training. (WIC 16001.9)
TILP 1 (8/17)
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