TRANSITION PLANNING COURT FORM

YOUTH-DEVELOPED DISCHARGE HEARING FORM
NAME:
I am under 21, and I want to stay in care:
DATE OF BIRTH:
 Yes
 No
 I am already 21
My Reasons for Wanting to Stay in Care or Leave Care:
HOUSING PLAN/DAILY EXPENSES
Address Where I Will Live:
Monthly Housing Cost & Living Expenses:
 Yes
I Have a Monthly Budget:
My Back-Up Housing Plan:
 No
My Concerns/Comments:
EDUCATION/VOCATIONAL TRAINING
My Current Educational/Vocational Level:
My Education Plan for Next 12 Months:
My Long-Term Educational Goal:
Financial Aid Documents Completed/Up To Date:
My Concerns/Comments:
 Yes
 No
 Yes
 No
EMPLOYMENT/CAREER
I Need Assistance Finding Employment:
Contact Information for Current Employer:
My Monthly Income from Employment:
My other Monthly Income (and Source of that Income):
My Long-Term Career Goal:
My Concerns/Comments:
The Pennsylvania Child Welfare Resource Center
202: Planning with Youth in Transition: Tips, Tools, and Techniques
Handout #12, Page 1 of 2
HEALTH
Name of Health Insurance Plan After I Leave Care:
Contact Information for Primary Care Physician:
My Continued Health & Mental Health Needs:
(dental, therapy, substance abuse, family planning, other medical needs, etc.)
Contact Information for My Other Health Care Providers:
My Concerns/Comments:
CHILDREN (IF APPLICABLE)
Health Insurance Plan for Child(ren):
Contact Information for Child(ren)’s Primary Medical Provider:
Contact Information for Child Care Provider(s):
I Have Enough Money to Pay for Child Care:
 Yes  No
I Have Applied for Child Care Subsidies?
 Yes  No
Amount of TANF (welfare or public assistance) Received for Child(ren):
Amount of Child Support Received for Child(ren):
My Concerns/Comments:
OTHER CONCERNS:
I Do Not Have the Following Important Documents (circle):
social security card
birth certificate
state ID/driver’s license
passport
immunization/medical records
education records
health insurance card
voter registration
credit report
bank account/savings account
registration for selective service (if male)
immigration documents (if applicable)
I Have Concerns About My Involvement with the Juvenile Justice System and Need Help Getting My Records Expunged:
 Yes  No  N/A
I Still Need Support with My Immigration Status:
 Yes  No  N/A
I Am Aware of Mentoring Programs or Other Programs That Provide Positive Connections With Adults:  Yes  No
My Concerns/Comments:
MY KEY CONTACTS:
Contact information for Person/People I Can Call in an Emergency (i.e., housing falls through, I get really hurt/sick, etc.):
I have participated in the development of this transition planning court form and believe the information in the form is accurate.
Youth’s Signature: _____________________________________________
Date: _____________
Private Provider/DHS Worker’s Signature: _________________________
Date: _____________
Judge’s Signature: _____________________________________________
Date: _____________
The Pennsylvania Child Welfare Resource Center
202: Planning with Youth in Transition: Tips, Tools, and Techniques
Handout #12, Page 2 of 2