Form Step 8 - Supportive Transitional Emancipation Program Transitional Independent Living Plan Page 4
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7CAREER
Career Goal (Continued)
My career Service Provider Is:_______________________________________________________________________________
My Service Provider will help me achieve my career goals by:
1.
____________________________________________________________________________________________________
2.
____________________________________________________________________________________________________
3.
____________________________________________________________________________________________________
I am achieving my career goals:
YES
NO
Supporting documentation:__________________________________________________________________________________
HEALTH COVERAGE
IF YES, MY SOURCE OF COVERAGE:
I AM CURRENTLY ON MEDI-CAL:
I CURRENTLY HAVE HEALTH COVERAGE:
YES
NO
YES
NO
IF YES, MY SOURCE OF COVERAGE:
I CURRENTLY HAVE DENTAL COVERAGE:
YES
NO
IF YES, MY SOURCE OF COVERAGE:
I CURRENTLY HAVE VISION COVERAGE:
YES
NO
If I do not have health, dental or vision coverage my Service Provider plans to help me obtain coverage by:________________
_____________________________________________________________________________________________________
I would like information on the following:
Drug Rehabilitation
Alcohol Rehabilitation
Tobacco Cessatio
Other (specify) :__________________________________________________________________________
None
My health Service Provider is:______________________________________________________________________________
My Service Provider will assist me by:________________________________________________________________________
Additional health needs:
1.
___________________________________________________________________________________________________
2.
___________________________________________________________________________________________________
3.
___________________________________________________________________________________________________
My Service Provider will assist me by:_________________________________________________________________________
HOUSING
My current living situation is (check all that apply) :
With spouse
With minor children
Alone renting an apartment or house
Transitional Housing
Host Family
With parent
With roommate renting an apartment or house
With relatives
College Dorm
Homeless
Shelter
Section 8 Vouchers
Unsafe
Temporary
With friends
Other (specify): ______________________________________________________________________________________
My current living situation is safe:
YES
NO
If NO, my Service Provider will help me gain a safe living environment by:____________________________________________
_______________________________________________________________________________________________________
I have changed residences during the previous 12 months because:_________________________________________________
I am currently on the transitional housing waiting list:
YES
NO
I am currently on the Section 8 voucher waiting list:
YES
NO
My housing needs are:____________________________________________________________________________________
______________________________________________________________________________________________________
My housing Service Provider is: _____________________________________________________________________________
My Service Provider will assist me by:________________________________________________________________________
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Parent category: Legal