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Independent Living Services

New Alternatives Referral Application

We're glad you're here!

By completing this referral form, you will help us understand the unique needs and goals of those you are referring, enabling us to develop a personalized support plan that aligns with their aspirations. We encourage you to provide detailed information to ensure that we can offer the most effective assistance possible. 

Your role is vital in guiding individuals toward the skills and confidence they need to thrive independently.

An eligible youth is an individual who:

  1. Is diagnosed with a serious emotional disturbance/serious mental illness or co-occurring mental illness and substance use disorder;
  2. Has a functional impairment and a history of difficulty in functioning successfully in the community, school, home, or job; or who will need services from the adult mental health system;
  3. Is not currently assessed as being dangerous to self or others or otherwise in need of hospitalization;
  4. Is age 18 to 21.
No file selected

Identifying Information

First Name *
Last Name *
Receiving Medicaid (SSI)
Receiving SSI
SSI application has been submitted
The client has applied for and has been denied SSI

Referral Source

First Name *
Last Name *
Current placement type
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Does the client require an accessible unit or have any accommodation needs

Behavioral Health Information

No file selected
Dual diagnosis
Substance use issues
Suicide attempts
Self-harm behavior’s
Problems with aggressive behavior
Sexually inappropriate behavior
Medication compliance
Level of support dequired
Currently in substance abuse or mental health treatment

Hospitalization(s) in the past two years due to mental health concerns

Systems currently involved or pending involvement
Systems currently in custody

Legal Status

Has the client had any criminal activity in the last five years?

Physical Health Information

Diagnosed physical disability
Will the physical health diagnosis affect the youth’s ability to successfully transition?
Is this a pregnant youth?
Is this a parenting youth?
First Name
Last Name
First Name
Last Name
Are the children in the youth’s care?

Educational Information

Highest level of education
Last grade level completed
Is the youth currently attending an educational program?
If yes, is this a post-secondary setting?
Has the youth ever received special education services?
No file selected

Support Needs

Managing medications
Meals/grocery shopping
Money management
Household chores
Crisis management
Phone calls
Social/recreation
Employment/volunteering
Hygiene
Public transportation
Completing forms
Supportive counseling
How often would the applicant like to see a support worker

Additional Support

We proudly partner with the Department of Social Services and various residential and juvenile justice programs to offer advocacy, education, and assistance to empower young people to make healthy choices.
 

If you are a partner and would like more information on the Community Resource Program, REACH, Young Voices, and FORGED please call 605-496-8691.

  • Joshua D.
    Joshua D.

    This place is amazing with very helpful staff!!!

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