South Carolina Department of Social Services

MONTHLY NYTD SERVICES TRACKING FORM

Youth’s Name: DOB:

Youth’s Placement Provider: Date of Services:

Name of Person Completing this Form:

Telephone: ( ) E-Mail: Today’s Date:

Independent Living Needs Assessment nn Casey Life Skills / / 20 nn PATTY / / 20 nn Other:

Service Provided By:

Academic Support (Elementary through High School) nn Tutoring nn School Sponsored Field Trips nn Senior Expenses nn Summer School nn Graduate Awards nn GED Prep nn Study Skills/Literacy Training nn Governor’s School Expenses nn Academic Counseling nn Application for Adult Education nn Books/Supplies for Specialized Classes nn Scholar’s Programs Recommended by School nn Other:

Service Provided By:

Post-Secondary Educational Support (College or Vocational Training) nn Counseling About College nn Tutoring nn SAT/ACT Prep Classes nn Non ETV College Coursework nn Non ETV Vocational Coursework nn College Campus Visits nn Pre College Expenses (Applications) nn Assistance in Applications for ETV nn Workshops on Educational Choices nn Transport to College Goal Sunday nn Assistance and Information about Financial Aid, Scholarships and Loans nn Other:

Service Provided By:

Career Preparation nn Assistance in Completing Job Applications nn Job Referrals nn Assistance in Resume Writing nn Job Shadowing nn Social Skills Training Related to Employment nn Career Exploration and Planning nn Identifying Potential Employers nn Use of Career Resource Libraries nn Job Readiness Courses nn Assistance with Online, Media, and In Person Job Searches nn Assistance in Understanding Employee Benefits Coverage nn Other:

Service Provided By:

DSS Form 30254 (JUL 16) Edition of MAR 11 is obsolete.

Employment Program or Vocational Training nn Employment Programs nn Vocational Training nn On the Job Training nn Certification Courses nn Other:

Service Provided By:

Budget and Financial Management nn Learning to Live Within a Budget nn Assistance in Opening and Using a Checking and Savings Account nn Accessing Information about Completing Tax Forms nn Developing Consumer Awareness and Smart Shopping Skills nn Teaching Youth about Establishing and Protecting Their Credit nn Other:

Service Provided By:

Family Support and Healthy Marriage Education nn Helping Youth Make Positive Connections nn Family Independence Workshops nn Foster Parents Providing Instruction and Modeling Appropriate Family Relationships nn Information on Healthy Marriages, Spousal Communication, Parenting, Responsible Parenthood, Childcare Skills, Teen Parenting, Domestic and Family Violence Prevention nn Other:

Service Provided By:

Housing Education and Home Management Training nn Managing Security Deposits nn Managing Utilities nn Assistance and Training in Locating and Maintaining Housing nn Assistance in Completing a Rental Application and Acquiring a Lease nn Assistance in Understanding Tenant’s Rights and Responsibilities and How to Address Issues with a Landlord nn Home Management Training Includes Instruction in Food Prep, Laundry, Housekeeping, Living Cooperatively with Others, Meal Planning, Grocery Shopping, and Basic Maintenance and Repairs nn Other:

Service Provided By:

Health Education and Risk Prevention These Services May Include Providing Information About nn Hygiene nn Nutrition, Fitness and Exercise nn First Aid nn Prenatal Care nn Health Care Resources and Insurance nn Maintaining Personal Medical Records nn Sexual Development and Sexuality nn Pregnancy Prevention and Family Planning nn Substance Abuse nn Sex Education nn Healthcare Proxy nn Prevention of Sexually Transmitted Diseases nn Other:

Service Provided By:

DSS Form 30254 (JUL 16) PAGE 2

Mentoring

Only includes a mentor relationship facilitated by the state agency or its staff.

Service Provided By:

Notes:

Supervised Independent Living

Occurs when a youth is living independently under a supervised arrangement that is paid for or provided by the state agency.

Service Provided By:

Notes:

Education Financial Assistance nn Textbooks nn Computers nn Educational Supplies nn Fees nn Tuition and Scholarship Assistance nn School Travel nn GED and Other Educational Tests nn Personal Items nn College Deposits nn Child Care nn Lab Equipment nn Commuter Meals nn Adult Education, Non-ETV Vocational and College Courses nn Payment for Educational Preparations and Support Services nn Other:

Service Provided By:

Other Financial Assistance nn Interview and Work Clothing nn Furniture nn Senior Expenses (Pictures, Cap & Gown, Graduation Invitations) nn Esteem Building Activities (Participating in Schools Sports, Music Programs, and ROTC) nn Transportation Assistance (Commuter Allowances, Car Repairs) nn Professional Attire for Youth No Longer in Placement Who are In School or Working nn Dorm Showers, Apartment Showers, and “Pack-a-Sack” Program nn Stipends Provided for Participation in Youth Groups, GOALL and SCNYTD Youth Voice nn Other:

Service Provided By:

DSS Case Manager’s Name: Telephone: ( )

County/Regional Office: E-Mail:

Note: NYTD Services must be entered into CAPSS under the “Support Services/NYTD” tab monthly as services are provided.

DSS Form 30254 (JUL 16) PAGE 3