Youth & Family Services Program (CINS/FINS) Eligibility Guide



Please Note:
  • A youth may be given our number and may self-refer, the number may be given to a guardian who may call directly, or a cooperating agency staff may fill out this form and fax it to our office.
  • The youth can not have an open DCF/HKI case, or be on probation with DJJ.
  • The guardian will be contacted by us to offer services.
  • To qualify for non-residential counseling services, the child must be between 6-17 years old, and not be under DCF/HKI supervision for dependency (i.e. foster care) or for delinquency (i.e. have any assigned community service officer).
  • There cannot be a current DCF/HKI investigation for abuse, neglect or abandonment.
  • Youth and Family Services only services Hillsborough County.

Other comments: Any youth between the ages of 10 – 17 may go Hillsborough County Children’s Services for their short-term residential respite program, 3110 Clay Mangum Lane (813) 264-3807 Ext. 53159 or (813) 272-6606, 24 hours a day.

Required fields marked with: *



Referral Source Information



Date of Contact *


Referred by *


Referring Agency (if applicable)

()
-

Referral Phone *


()
-

Referral Fax Number



Referral Source Email



Youth's Information



First Name *


Last Name *


Sex


Race


Age

Date of Birth *
Year:   Month:  
<November 2020>
SunMonTueWedThuFriSat
25262728293031
1234567
891011121314
15161718192021
22232425262728
293012345
Birth date selected:  


Name(s) of Parent/Legal Guardian(s)


Email Address
()
-

Home Phone *

()
-

Work Phone

()
-

Cell Phone


Address

Street Address


City

State

Zip


Referral Source Information

Select all that apply:
School Failure, or frequent truancy, or suspension/expulsion, or learning disabilities.
Additional Notes:


Family parenting issues: or family history of abuse or reglect (prior DCF involvement); or family member (parent, guardian, or sibling) with prior or current criminal history.
Additional Notes:


Current use of alcohol, tobacco, or drugs, or charged with a drug related offense.
Additional Notes:


Behavior problems, including stealing; or running away from home; or association with negative peers; or that have a delinquency record.
Additional Notes:


Services Requested

Select all that apply:




If you would like a copy of this referral sent to you via email, please enter your email address below. If not, you may leave this field blank.


Email Address

 

The Housing Authority of the City of Tampa provides equal opportunity to participates in our housing programs. Any disabled person, outlined by the American With Disabilities Act, requiring a reasonable accommodation to make this process accessible may request such by contacting (813) 341-9101


Where can I get more Help?

Assisted Housing Information:
(813) 253-0551

Public Housing Information:
(813) 341-9101

ADA Web Site Compliance


Bookmark Facebook Twitter Del.icio.us Google

5301 W Cypress St, Tampa FL 33607
Map It!
THA is committed to ensuring that persons with disabilities have equal access to THA forms, notices, resources and services. THA is currently updating our website to improve its accessibility. In accordance with The Americans with Disabilities Act (ADA), these changes will include design elements taking the Web Content Accessibility Guidelines 2.0 into consideration.

If the format of any material/content on this website interferes with your ability to access information please contact us at (813) 341-9101.