ILP Self Referral | Polk Youth Services

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

Date picker

Legal Name (first and last)

Preferred Name (first and last)

Email

County you live in

Polk

Marion

Yamhill

Not Currently in District 3 (Polk, Marion or Yamhill)

City you are moving to if you are not currently in District 3?

Address

City you currently live in

Have you been in ILP?

Yes

No

If Yes, What County and who was your last ILP worker?

Was your case closed with DHS before you turned 18?

Yes

No

Unknown

Phone

Birthday

Month

Day

Year

Gender

Type of Placement

Anything else you want the new ILP Program to know about? Or you want the supervisor to know before they select a ILP worker for you.

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.