Children and Family Services

Referral Form

Dear Applicant,
If you are interested in THP+FC or THP+ housing please complete the attached referral form and submit it us. Your referral will be reviewed by the intake coordinator to identify if our program will best meet your needs. Please contact us with any questions you may have. Please note that completing this referral form does not guarantee placement with Monarch THPP-FC or THP.
General Information
Program Applying for: THP+   THP+FC
Street Address:
Home Phone:
Cell Phone:
Email Address:
Referral Source:
Are you currently pregnant OR soon to be fathering a new child that you will have custody of?  Yes   No
Do you have children Yes   No    If yes, how many are living with you?
Are you currently in foster care or in an out placement?   Yes   No
If yes, what is your current placement?  Group Home   THP   Foster Home   SILP   Other
If no, what was your emancipation date:
Are you currently on probation? Yes   No   Were you previously on probation?  Yes   No
Name of current/last social worker:
Name of current/last probation officer:

Education & Employment
Have you obtained any of the following? Certificate of Completion GED High School Diploma
What best describes your current education status?
Never attended high school
Dropped out of high school and not currently attending school
Attending high school or GED program
Received certificate of completion and not currently attending school
Received high school diploma/GED and not currently attending school
Attending vocational training school
Attending community college
Attending four year university
Obtained associates degree (AA) or technical degree and not currently attending school
Obtained bachelor's degree
Other - Specify:
If not enrolled in school, are you interested in enrolling in school?  Yes   No
Do you currently or did you previously have an IEP?  Yes   No
If enrolled in school, what school?
What best describes your current employment status?  Employed Part-Time  Employed Full-Time
Current Employer:
Not employed but actively seeking employment
Not employed and not actively seeking employment
If employed, what is your total income from employment in the last month?
What is your primary source of income?
Total monthly income from all sources:

Which of the following describes your general emotional state? (More than one is OK)
Stable   Happy   Sad   Confused   A little depressed   Very depressed   Unstable   None of them
Have you ever had a mental health diagnosis?  Yes   No   Unknown
If yes, please specify:
Do you currently have a therapist? Yes   No
If yes, Name:
We will not contact your therapist without your permission.
Do you currently have a psychiatrist? Yes   No
If yes, Name:
We will not contact your psychiatrist without your permission.
Do you receive SSI/SSDI: Yes   No   If yes, what do you receive SSI/SSDI for?
Please list all prescription medication that you take.
Medication Name Reason / Purpose Length
Physical Health
Mental Health
Please explain why
Have you been hospitalized in the last two (2) years? Yes   No
Please explain why
Have you ever been in a treatment program for substance abuse? Yes   No
If yes, name of program and length of stay
Do you have health insurance? Yes   No
If insured MediCal # MediCal Issue Date:
Other Health Insurance
Specify Other Insurer Other Insurance ID#
Family or Kin Support
Is your kinship/family network: Very Supportive   Supportive   Not supportive   No contact
Is your social network: Very Supportive   Supportive   Not supportive   No contact
Criminal History
Have you been convicted of a violent felony as an adult? Yes   No
Please explain

Location & Housing
Do you feel you have safe and stable housing? Yes   No
If no, do you need emergency shelter? Yes   No
What best describes your current living situation?
Foster care or out of home placement >>Specify
Renting own or shared housing (paying rent)
Living with relative or other person in stable housing (rent free)
College Dorm
THP-Plus program >>Specify
Other supportive transitional housing program >> Specify
Motel or Hotel
Other unstable housing situation (couch surfing with relatives, friends, or other people)
Emergency shelter, homeless or other unstable housing (street, car, etc.)
Institutionalized (just exited hospital, jail, mental health facility with no place to go) >> Specify
Do you require reasonable housing accommodation due to a disability? Yes   No
If yes, please complete a reasonable accommodation request form.
If you were to be placed into one of our housing programs, what type of housing do you think you would prefer?
Please rank from first choice to last choice:
Individual or shared apartment at scattered sites
Host home with a permanent adult
Community/single?site housing (also known as staffed housing)
If interested in host housing, do you have a permanent adult that you can live with? Yes   No   Unknown   N/A

What can we help you with?
Housing Employment Education
Other >> Specify:
What are your educational goals and how do you think our program could help you achieve them?
How would you describe yourself?
What are your greatest strengths that would help you be successful in our program?
What are some things that are getting in the way of your goals and/or challenges?
Have you ever been housed by a THP+ program or transitional housing program? Yes   No
If yes, which one(s) and for how long? Agency(ies):   # of Months:
Have you applied to other housing programs? Yes No   If yes, which program(s)?
Please review your answers before submitting, thank you.

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