(Send report to Joli Guenther, WAHRS, 2318 East Dayton Street, Madison, WI 53704, 15 Days after the end of the quarter)
Program
Name: ________________________________
City:
______________________________
Person
Completing This Report: ___________________
Report
Period: ____________________ ______________________
_______________
1.
Number of new youth provided
Transitional Living housing and supportive services __________(Total)
______ New
______ Reopen (new contact after case has been closed)
2.
Number of youth (counted
in #1) that were pregnant and/or parenting___________
Number
of children served with teen parent in #2 (above) ___________
3.
Locale Breakdown- Indicate the numbers of youth served that come from:
a.
___________County (ies) served by your program.
b. ___________Other served counties in Wisconsin.
c. ___________Unserved counties in Wisconsin.
d. ___________Other states.
*
The total of a, b, c, and d must equal #1.
4. Race (# and %)
American Indian or Alaskan Native Asian
Black or African American %
White
%
Native
Hawaiian or Other Pacific Islander
%
Not
Provided
%
5. Ethnicity
Not Hispanic
or Latino
_______
%
Hispanic or
Latino
_______
%
Not provided
_______
%
6. Gender (# and %)
Male %
Female
%
7.
Youth Issues Identified
(# and %)
Household Issues
%
Housing
Issues
%
School and
Education
%
Unemployment
%
Disability
%
Abuse and/or
Neglect
%
Alcohol and
Other Drug Abuse
%
Sexual Orientation/Gender Issues
%
Mental Health Issues
%
Health Issues
%
Family Dynamics
%
Other (Specify)
%
8. Discharge status of youth
(total should equal #1).
a. ______Youth secured independent living (other than home)
b. ______Youth returned home
c. ______Youth returned to the street or unknown destination
d.______ Youth is still in TLP program
9. What
percentage of youth went home or to a safe alternative? ________%
10.
Total number of volunteer hours donated directly to your program.
_______________