24.Housing: Group home: specify: Institution (jail, detention, hospital, prison, Type of Housing Adult PRTF) Permanent Child, specify level: Boarding house or other unlicensed facility Supportive Housing (ex. Andover, Foster Care (DSS) Homeless, please specify: street Independent Living Program) Rapid Response, how long: shelter campsite hotel car Transitional (ex. 30-day programs) Therapeutic foster care Other: If at shelter, how long? Recovery/Halfway house (long term) Runaway status Other, please specify: Family/Friend (temporary, not on lease) 25. Housing Stability Stable (safe, affordable housing that is the appropriate level of care for the individual) Unstable, specify: facing eviction insufficient income unsafe living condition homeless inappropriate level of care need for transition other, specify: 26.Source of income 27.Source of benefits: 28. Income: (check all that apply): No insurance No income support Medicaid Food and Nutrition Program (Food SSI/SSDI Parent/guardian Medicare Stamps) benefits Work First Medicaid/Medicare Yes Employment Unemployment benefits NC Health Choice No full time Retirement benefits Private Part time VA benefits IPRS (MH Only) WIC Day labor VA Benefits Yes Other, explain: No 29. Disability Benefits If not currently receiving SSI/SSDI has individual applied? Yes No N/A Status: 1st Application Pending Reconsideration Appeal 30. Medicaid Status If not currently receiving Medicaid has individual applied? Yes No N/A Status: 1st Application Pending Reconsideration Appeal If youth, IEP completed: 31.Educational and Vocational information: Yes No N/A Highest grade completed: If youth, 504 Plan completed: Working on or completed GED Yes No Yes No N/A Currently enrolled in school: Yes No If known, please indicate IQ: If applicable, name of school: If youth, educational classification: Currently job seeking: Yes No If youth, participating in CFST? Enrolled in job skills program: Yes No Yes No Enrolled in VR services: Yes No Behind grade level/held back: Yes No Enrolled in volunteer/day program: Yes No
24.Housing: Type of Housing Permanent Supportive Housing (ex. Andover, Independent Living Program) Transitional (ex. 30-day programs) Recovery/Halfway house (long term) Family/Friend (temporary, not on lease) Group home: specify: Adult Child, specify level: Foster Care (DSS) Rapid Response, how long: Therapeutic foster care Runaway status Institution (jail, detention, hospital, prison, PRTF) Boarding house or other unlicensed facility Homeless, please specify: street shelter campsite hotel car Other: If at shelter, how long? Other, please specify: 25. Housing Stability Stable (safe, affordable housing that is the appropriate level of care for the individual) Unstable, specify: facing eviction insufficient income unsafe living condition homeless inappropriate level of care need for transition other, specify: 26.Source of income (check all that apply): No income SSI/SSDI benefits Employment full time Part time Day labor support Parent/guardian Work First Unemployment benefits Retirement benefits VA benefits 27.Source of benefits: No insurance Medicaid Medicare Medicaid/Medicare NC Health Choice Private IPRS (MH Only) VA Benefits Other, explain: 28. Income: Food and Nutrition Program (Food Stamps) Yes No WIC Yes No 29. Disability Benefits If not currently receiving SSI/SSDI has individual applied? Yes No N/A Status: 1st Application Pending Reconsideration Appeal 30. Medicaid Status If not currently receiving Medicaid has individual applied? Yes No N/A Status: 1st Application Pending Reconsideration Appeal 31.Educational and Vocational information: Highest grade completed: Working on or completed GED Yes No Currently enrolled in school: Yes No If applicable, name of school: Currently job seeking: Yes No Enrolled in job skills program: Yes No Enrolled in VR services: Yes No Enrolled in volunteer/day program: Yes No If youth, IEP completed: Yes No N/A If youth, 504 Plan completed: Yes No N/A If known, please indicate IQ: If youth, educational classification: If youth, participating in CFST? Yes No Behind grade level/held back: Yes No