ODHS Referral Independent Living Program (ILP) Form

ILP Contractor to Provide Services:

Date of Referral:

Month

Day

Year

Young Person Information

Legal First Name (please include preferred name in "quotes" if applicable:

Middle Initital:

Last Name:

Birthday

Month

Day

Year

Age:

Case Number:

Person Number:

School:

Highest Grade level Completed:

Mailing Address:

County of Residence:

Young Person's Phone Number:

Young Person's Email Address:

Race:

Primary Language:

Gender:

Preferred Pronouns:

Is the young person a parent?

Yes

If yes, does the young person have custody?

Yes

Living Situation:

Caseworker Information

First Name:

Last Name:

Cell Phone Number:

Email Address:

Branch or Tribal Office:

Mailing Address:

City:

ZIP Code:

District:

Supervisor's Name:

Supervisor's Email:

Courtesy Worker, If Applicable:

First Name:

Last Name:

Phone Number:

Branch or Tribal Office:

Email Address:

Resource Parent

Is there a resource parent?

Yes

Residential / Group Home

If yes, enter primary resource parent's information below. Group Home or Residential Managers info. can also go here. If not, skip to plan type.

First Name:

Last Name:

Email Address:

Phone Number:

Plan Type

Permanency Plan:

Concurrent Plan:

Anticipated Changes:

Eligibility Confirmation

Age 14 or older and currently in substitute care with the Oregon Department of Human Services (ODHS) or one of the nine federally recognized Tribes in Oregon.

Former foster youth with at least 180 days of substitute care after age 13 and dismissed after the age of 14 (ODHS or Tribal) and has not yet reached age 24.

Additional Information

Is this young person aware of and supportive of this referral?

Yes

Has this young person participated in ILP services before?

Yes

If yes, when and with whom?

Has a Transition Plan and Youth Assessment Summary been completed?

Yes

If yes, submit documents with this referral.

Strengths

What strengths does this young person have that will help them transition to adulthood?

Behavioral Needs

Are there any behavioral needs (including aggressive or sexual behaviors) you want the provider to be aware of? If yes, please explain:

Contact Restrictions

Are there any contact restrictions? If yes, please explain:

Does this young person prefer ILP staff of the same gender?

Yes

Health Needs

Does this young person have any health needs, including mental health needs, that could affect their involvement in ILP activities? If yes, please explain:

Are there any other support services being provided? If yes, please explain:

Juvenile Justice System

Is this young person currently involved with the juvenile justice system? If yes, state the name and phone number of the parole officer, probation officer or juvenile court counselor.

Additional Comments

Is there more to know about this young person that may help the provider in the following ways:

● To provide support services in the best way possible.

● To support the youth with their family circumstances. For example, parent(s) status, sibling(s) status, or anything that could help minimize re-traumatization.

● To accommodate sexual orientation, gender identity and expression (SOGIE).

Add Comments Here:

Caseworker Signature

Signature

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Caseworker Name (First and Last):

Date

Month

Day

Year

Independent Living Program CHILD WELFARE (ILP) Referral Form Instructions

Youth Transitions Program Page 6 of 7 100-372271_CF 0080 (10/2024) The CF80 Independent Living Program (ILP) Referral form must be used to refer a young person aged 14 or older for contracted ILP skill-building services. The CF80 must be completed in full.

REFERRAL PROCESS

Statewide: Send the completed CF80 directly to the ILP provider. The CF80 is sent to the ILP provider serving the county where the young person lives. See below for the statewide list on the ODHS website.

PROVIDER PROCESS

A young person is not automatically enrolled for ILP services on referral. The ILP provider must respond within five business days to state the status of the referral as follows:

● Accepted

● Placed on a waiting list,

or ● Not accepted due to missing information.

If the young person is placed on a waiting list, the provider will give more information about a timeline for enrollment.

TRANSITION PLANNING

A caseworker must ensure a Comprehensive Transition Plan (CTP) CF 69A for young people aged 14 or older is completed. Caseworkers must also ensure the CTP includes completing a life skills assessment. This occurs before a planning meeting, also known as a Youth Decision Meeting (YDM). The CTP must identify goals and services in a variety of areas. The CTP also informs service delivery or support services that ILP providers will offer. If a young person is receiving ILP services the caseworker and ILP Provider will partner to support them.

The caseworker must:

● Monitor the implementation of services

● Make reasonable efforts to ensure timely and appropriate services are available Page 7 of 7 100-372271_CF 0080 (10/2024)

● Note ongoing progress, barriers, plans and changes throughout the life of the case, and

● Make regular reviews during monthly face-to-face contact with the young person and during 90-day case plan reviews.

The caseworker’s supervisor must review and approve the documentation. The caseworker must convene benchmark review meetings six months before the child reaches 18 years of age and 90 days prior to anticipated case closure. The caseworker gives this to the court during the young person’s next permanency hearing.

413-030-0445 Development of the Comprehensive Transition Plan

413-030-0449 Review of the Comprehensive Plan

413-030-0454 Benchmark Review of the Comprehensive Transition Plan

ADDITIONAL ILP INFORMATION

The following websites have more information about ILP providers and other services available through ODHS:

ODHS website: https://www.oregon.gov/odhs/foster-care-transition/Pages/default.aspx

ODHS Procedure Manual: https://www.oregon.gov/odhs/rules-policy/Documents/cw-procedure-manual.pdf

You can get this document in other languages, large print, braille or a format you prefer free of charge. Contact ODHS Youth Transitions staff at ILP.Central@odhsoha.oregon.gov or 503-945-5684 (voice/text). We accept all relay calls.