Program Name: ________________________________

City: ______________________________

Person Completing This Report: ___________________

Report Period: _____________________________________ (reporting year runs January-December)

1.  # youth seen individually, and/or with family member(s) ______ (new/re-opened cases only)

         ______ New ______ Reopen (new contact after case has been closed)

      _____________ Continued (1^st quarter only - these are in addition to #1 above) 

Indicate the NUMBER OF YOUTH served that come from (should total #1 above):

a. ___________County (ies) served by your program. 
b. ___________Other served counties in Wisconsin. 
c. ___________Unserved counties in Wisconsin. 
d. ___________Other states.

2. # of clients from #1 above seen face to face with problems related to the effects of W-2 sanctions. ________ 

3.  Race of youth from #1 American Indian or Alaskan Native    

  (youth may identify with  Asian          

  more than one race)  Black or African American     

                  White        

                  Native Hawaiian or Other Pacific Islander _______ 

                  Not Provided      

                  Multiple/Other not provided      

4.  Ethnicity    Not Hispanic or Latino      

(total should = #1 above) Hispanic or Latino      

                        Not Provided        

5.  a.  Gender   Male    

(total should = #1 above) Female     

  b.  total number of youth from #1 that identify as LGBTQ    
 

6.  Runaway Status  At Home     

    (of youth in #1)  Runaway     

                  Throwaway     

                  Homeless     

                  Emancipated     

                  J.J. Placement     

                  Child Welfare Placement   

                  Other      

7.  Youth/Family Issues Identified  Physical Abuse/Assault    

      (by youth in #1)    Sexual Abuse/Assault    

      Alcohol and Other Drug Abuse   

                              Emotional Abuse    

                              Neglect      

                              Family Dynamics    

                              Sexual Orientation/Gender Identity  

      School/Educational    

                              Housing Issues      

                              Unemployment     

                              Mental Health Issues    

                              Health Issues     

                                                       Physical Disability    

                                                      Mental Disability     

                              Other       
 

 

8. Discharge status of youth seen face-to-face (total should equal #1). 

      a. ______Youth returned home

      b. ______Youth was placed in a safe alternative (other than home)

      c. ______Youth returned to the street or unknown destination 

9. Number of new youth seen in counseling groups _________

Do not include youth counted in #1 
 

10. _______Total # of families that received face-to-face counseling.

11. ________Total # of face-to-face counseling sessions.

12._______  Number of youth sheltered 
13. _______Total number of telephone contacts.   14.  _________ Total number of electronic contacts (email, etc.)

      ________Initial Counseling Calls   ________ initial electronic counseling contact

      ________Follow up Counseling Calls   ________ follow up electronic counseling contact

      ________Information and Referral Calls   ________ information and referral electronic contact

15.  ______ Number of Volunteers recruited

16.  _______Number of volunteer hours donated directly to your program.

17.  _______ Number of youth provided intensive off-site services (through schools, community centers, etc.)

18.  ________Number of individuals reached through community/school presentations

___________ Youth ____________ Adults/Community Members

The following questions apply to programs providing formal street outreach to runaway and homeless youth and youth at risk.

19. _______Total number of street outreach contacts. (may be duplicated)

20. _______Total number of youth in #18 who were provided more intensive street based services (unduplicated).