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Independent Living Program Self-Referral Form

(You must be 18+ to complete this form)

Were you in foster care in Oregon ?
Yes
No

If no, please contact the state you were in care and get documentation regarding the date you entered care and when your case was closed. Complete the referral, and send documentation to ShannonS@polkyouthservices.com

County you live in
Polk
Marion
Yamhill
Not Currently in District 3 (Polk, Marion or Yamhill)
Have you been in ILP?
Yes
No
Was your case closed with DHS before you turned 18?
Yes
No
Unknown
Birthday
Month
Day
Year
Gender
Type of Placement
I would like help with (choose all that apply)
Do you have a preference for the gender of your ILP worker? Please note: Selecting a specific gender preference may result in a longer wait time until a worker becomes available.

Please Give Polk Youth Services ILP 5 Business Days to gather your information and check eligibility. The ILP Supervisor will reach out after eligibility is confirmed via e-mail to let you know the status of your referral.

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