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Independent Living Program Self Referral Form

Were you in Oregon care?
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
Have you been in ILP?
Yes
No
Birthday
Month
Day
Year
Gender
Type of Placement
I would like help with (choose all that apply)
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