TAPP English Questionnaire

Everyone has special gifts, values and dreams. Sometimes, it takes just one person who believes in you to help you reach those dreams. The Teenage Pregnancy and Parenting program gives you the opportunity to partner with a supportive and encouraging case manager who will help you explore your goals and make decisions that are meaningful to you. This program helps you find your strengths and interests so you can reach your goals and be the best parent for your child. If you’d like to find out if you’re eligible for the free services provided by the TAPP program, please complete and submit this form.

Your Name
Address
MM slash DD slash YYYY
Referral Source
How old are you?
MM slash DD slash YYYY
Are you (or your partner) pregnant or expecting a baby?
Do you have any children you are parenting?
Are you currently enrolled in, or think you may be eligible for, the Cal Learn Program?
Note: Youth are eligible for and required to participate in CalLearn if: • youth is CalWorks recipient or youth lives with parents who are CalWorks recipients; and, • youth is under age 19 and did not graduate high school; and, • youth lives with his or her own children.
Are you willing to participate in case management, including regular face-to-face visits with an AFLP staff member?
What language would you prefer resource materials?
Which of the following ways would you like to receive information? (check all that apply):
Do you have safe, stable housing?
Do you have consistent access to enough healthy food to meet your [and your child(ren)’s] needs?
Do you worry about losing your phone, water, electricity, or gas because you or your family can’t pay the bills?
Are you able to get clothing or other needed items for yourself [and your child(ren)]?
Do you have to miss work or school or go without health care because you don’t have a way to get there?
[If parenting] Are problems getting childcare making it difficult for you to work or go to school?
Do you have health insurance?
Do you [or your child] have any unmet medical needs?
Do you need help with emotional well-being or mental health concerns such as feeling anxious, irritable, restless, down, depressed, or hopeless?
Do you need help to stop using drugs or alcohol?