STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPPORTIVE TRANSITIONAL EMANCIPATION PROGRAM
(STEP TILP)
18
21
TRANSITIONAL INDEPENDENT LIVING PLAN
FOR
UP TO
YEARS OLD
PERSONAL DATA
START DATE OF PROGRAM:
COMPLETION DATE:
NAME:
SSN:
DATE OF BIRTH:
AGE:
GENDER:
_
_
M
F
COUNTY OF THE LAST HELD DEPENDENCY/WARDSHIP:
NAME OF LAST SOCIAL WORKER:
CURRENT ADDRESS:
CITY:
COUNTY:
STATE:
ZIP:
TELEPHONE:
(
)
MAILING ADDRESS IF DIFFERENT:
CITY:
COUNTY:
STATE:
ZIP:
OTHER TELEPHONE:
(
)
TRIBAL AFFILIATION:
IF YES, NAME OF TRIBE:
ETHNICITY:
LANGUAGE:
YES
NO
EMANCIPATED FROM:
EMANCIPATION DATE:
FOSTER CARE
PROBATION
RELATIVE CARE
THE COUNTY WILL CHECK IN WITH ME:
OTHER (SPECIFY): ____________________________________________
MONTHLY
QUARTERLY
EVERY 6 MONTHS
ANNUALLY
CURRENT IDENTIFICATION:
MY PRIMARY SERVICE PROVIDER IS:
CA ID CARD
CA DRIVER’S LICENSE
PASSPORT
VISA
EDUCATION
Completed schooling
Type of education I have completed:
Up through 9th Grade
Up through 10th Grade
Up through 11th Grade
Up through 12th Grade
High School Diploma
GED
Vocational Education
Community College
4 year College/University
Other (specify) :______________________________________________________________
School Attended:______________________________________________________________________________________
Course of Study:__________________________________________________________ Date Completed:______________
Current schooling
Type of education I am currently enrolled in:
High School
GED Courses
Vocational Education
Community College
4 year College/University
Other (specify) :______________________________________________________________
School Attended:______________________________________________________________________________________
Course of Study:____________________________________________ Projected Completion Date:___________________
Proof of Enrollment (attach) :
Report Card
School Transcripts
Proof of Registration
Other (specify) :___________________________________________________________________________________
Educational Goals
Grade Point Average: _______
During my time in STEP, my educational goals are:
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
STEP 8 (8/02)
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