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 (1st 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
c. ___________Unserved counties in
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
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.
________Initial Counseling
Calls
________Follow up Counseling
Calls
________Information and
Referral Calls
14.
______
Number of Volunteers recruited
15.
_______Number
of volunteer hours donated directly to your program.
16.
_______
Number of youth provided intensive off-site
services (through schools, community centers, etc.)
17.
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.
18. _______Total
number of street outreach contacts. (may be duplicated)
19. _______Total
number of youth in #18 who were provided more intensive street based services
(unduplicated).