SPY Service Interest Form
Welcome to Safe Place for Youth (SPY)!

Please fill out the following information to the best of your ability and a SPY staff member will follow up with you shortly.

Please note that you can skip any question you do not feel comfortable answering at this time! All of this information will remain confidential within SPY and will not be shared with anyone else without your permission first.
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Personal and Contact Information
First Name
Last Name
Nickname/Preferred Name
Pronouns
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Current Age
Phone Number
Email Address
What is the best way to reach you?
Clear selection
Is it okay to leave a voicemail on this number?
What language are you most comfortable with?
Clear selection
Additional Personal Information
Housing Information
What is your current living situation?
Are you sleeping outside? in a car? at a friends or family's spot? at your own place? how much longer can you stay there?
What part of town did you mostly stay in this month?
Please check all that apply
Access Center/Outreach
What services are you interested in receiving?
Please check all that apply
Have you received services (housing, health care, benefits, counseling, etc.) within the last year?
YCES
Have you ever been involved in the Foster Care system?
Not sure if you were involved? Here are some additional questions that may help you answer more confidently: Have you ever lived with someone outside of your immediate family?  Have you lived in a group home? Have you ever had a social worker, either now or when you were younger? If so, you may be a former foster youth!   Note- your response will NOT prevent you from accessing services with SPY!  Rather, it helps inform us if you're potentially eligible for additional resources.
If yes, who is your DCFS/SW? 
Have you ever been involved with the juvenile justice  system?
Including juvenile camp or probation?  Note- your response will NOT prevent you from accessing services with SPY!  Rather, it helps inform us if you're potentially eligible for additional resources.
If yes, who is your PO?
Do you attend a local college?
If you are attending a school other than SMC, WLAC or UCLA, please use the "other" option to tell us which one!
Are you connected to a voucher?
Clear selection
Are you connected to another agency? If so, do you know the CM & Agency.
Anything else you wish to tell us?
Submit
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