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AI AVENUES OF INDEPENDENCE


Screening Form


If you or someone you know is a youth (age 18-25) who is in need of housing please complete the form below

* Indicates field is required.

YOUTH INFORMATION

First Name *
Age
Date Of Birth (MM/YYYY) /
Gender Male Female

CALLER INFORMATION

You are referring yourself

First Name
Last Name
Relationship to Youth
Telephone *
Alternate Telephone/Email Address

CURRENT HOUSING SITUATION

Staying with :
Family Member
Foster/Group Home
Shelter
Homeless/Streets
  OR Incarcerated in
       CAMP
       Juvenile Hall
       Jail
Other 

Briefly explain why housing is needed at this time? Why can youth no longer remain in current situation? Consider : current housing situation placement history, conflict/problems/difficulty in housing situation, etc.

School:

Enrolled
Not Currently Enrolled
Diploma/GED
Want to get GED
Other Educational/Vocational Goals  

Employment History:

Working
Looking for Employment
Never been Employed
Unable to work due to Disability

Behavioral Issues:

Sadness/Depressed Mood
Arrest Record
Harmful to Others
Opposition/Defiant
Physical Limitations
Property Destruction
Harms/Threatens Others
Self Harming Behaviour
Sexual Acting Out
Sleep Problems
Substance Abuse
Violent Behaviour/Weapons Use

Mental Health History:

Currently Taking Medication :                                    Yes  No                Supply On Hand :              Yes  No
Currrently in Treatment with Therapist or Psychiatrist :Yes  No                History of Hospitalizations :Yes  No
Youth has Medi-Cal :                                                Yes  No

30 Day Goal :

Date Housing is needed * :     

Transportation to AI Available :Yes  No



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Address: P.O. Box 561706, Los Angeles, CA, 90056   |   Phone: (323) 348-4109   |  Email: info@avenuesofindependence.org

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