Sequential Intercept Model · Transition Age Youth Mapping

El Paso County
Community Toolkit

This toolkit brings together the work of the El Paso County Transition Age Youth Sequential Intercept Model mapping: the four priorities the community chose, the resources the county already has for young people ages 16 to 24, and the action plans the priority teams wrote.

Facilitated by Lynda Frost, Lynfro Consulting, and Douglas Smith, D-Degree Consulting, for the Texas Judicial Commission on Mental Health.

The four priorities

  1. Justice and Mental Health Data Sharing
  2. Transitional Liaison for Transition Age Youth
  3. Transitional Housing for Transition Age Youth
  4. Specialized Docket for Transition Age Youth
01 El Paso County Resources Every resource named during the mapping, organized by intercept, with the ones built for ages 16 to 24 listed first. 147 entries, downloadable as a spreadsheet. 147 resources 02 Best Practices The full SIM Best Practices library, covering every intercept for youth and adult systems, with the research behind each practice. It opens in a new tab. Opens the library 03 Priority Action Plans The plans developed by each priority team, including objectives, tasks, team leads, and the next meeting. Printable copies 04 Team Lead Toolkit Materials for priority team leads: a playbook, meeting agendas, a progress tracker, and a checklist. 5 tools

Why a Transition Age Youth SIM

Young people ages 16 to 24 are becoming adults while the systems around them change too. In Texas, a 17-year-old is treated as an adult in the criminal justice system, and many youth services end at 18 or 21. Supports built for children or for adults often miss the years in between.

A Transition Age Youth SIM maps the local system with this age group in mind, so the county can see where young people fall through the gaps and where they can be connected to help instead of moving further into the justice system.

How the process worked

The mapping took place in two parts: a virtual session followed by a full-day in-person workshop. Before the sessions, the planning team met to shape the work, community partners were interviewed, and a resource survey gathered what El Paso County already offers young people.

At the in-person workshop on October 14, 2026, participants reviewed the resources at each intercept, rated ideas for change, and chose four priorities. A team formed around each priority and drafted its action plan.

Planning team

The planning team guided the mapping from the first planning meeting through the workshop.

  • Annalisa Davila, Deputy Director, El Paso County CSCD
  • Josue Lachica, Assistant Director, Paso del Norte Center at the Meadows Mental Health Policy Institute
  • Enrique Mata, Executive Director, Paso del Norte Center at the Meadows Mental Health Policy Institute
  • Chief Rosie Medina, El Paso Juvenile Probation Department
  • Magdalena Morales-Aina, Director, El Paso County Community Supervision and Corrections Department
  • Judge Anna Perez, 41st District Court of Texas

About this toolkit

The Sequential Intercept Model identifies the points at which a young person with behavioral health needs may be redirected toward services rather than further into the justice system. This toolkit is a working document for the El Paso County priority teams and for anyone who serves young people ages 16 to 24.

El Paso County Transition Age Youth Sequential Intercept Model Community Toolkit.
Built from the El Paso County action plans and resource tables. Prepared by D-Degree Consulting and Lynfro Consulting for the Texas Judicial Commission on Mental Health.

El Paso County Resources

Every resource named during the mapping, organized by the intercept where it does its work. 147 entries, each linked where a link exists.

No resource matches that search.

Download the full resource list

Every resource on this page is available as a spreadsheet, with one sheet listing all 147 and a separate sheet for each intercept. Columns include category, resource, website, phone, and notes, so the list can be sorted, filtered, or loaded into a referral system.

Download Excel 41 KB
Intercept 0

Community Services and Crisis Response

Where young people and families first meet help, before any justice involvement.

What El Paso County already has 93 resources

Built for ages 16 to 24
  • UTEP Opportunity Youth Action Network and Breakthrough 915
    What it does:
    Countywide work group reconnecting young people out of school and work
    Ages served:
    16 to 24
    How it serves this age group:
    Built around disconnected young adults; tracks them on a public data dashboard.
  • Workforce Solutions Borderplex, NextForce
    What it does:
    Career counseling, paid work experience and job training
    Ages served:
    14 to 24
    How it serves this age group:
    Targets young people in foster care, out of school, homeless or justice involved.
  • El Paso Human Services, PRIDE Center
    What it does:
    Foster Youth Transition Center: case management, school, jobs, referrals
    Ages served:
    16 to 25
    How it serves this age group:
    Built for young people leaving foster care, including those with justice involvement.
  • El Paso Human Services, Winchester House
    What it does:
    Transitional living for former foster youth
    Ages served:
    Young men 18 to 25
    How it serves this age group:
    Housing with independent living support for young men aging out of care.
  • El Paso Center for Children, Youth Outreach and Housing
    What it does:
    Drop-in center, two transitional living programs, rental help, street outreach
    Ages served:
    Drop-in 11 to 24; rental help 18 to 24; shelter 11 to 17
    How it serves this age group:
    Reserved slots and life skills for young adults; the shelter stops at 17.
  • Texas DFPS, Preparation for Adult Living and extended foster care
    What it does:
    Life skills, transition planning and continued care for youth in foster care
    Ages served:
    Youth in care; extended care to 21
    How it serves this age group:
    Transition planning is the purpose; requires foster care history.
  • Methodist Children's Home, Transition Services
    What it does:
    Independent living, college and job support for former residents and foster youth
    Ages served:
    18 to 25
    How it serves this age group:
    Built for the move to adult life; run from Waco, not the El Paso office.
  • Big Brothers Big Sisters of El Paso, Big Futures
    What it does:
    One-to-one mentoring with career readiness
    Ages served:
    Big Futures 16 to 24
    How it serves this age group:
    Keeps a mentor in place into early adulthood, focused on work and school.
  • Aliviane Youth Recovery Community
    What it does:
    Peer recovery support, life skills, sober activities, warm handoffs
    Ages served:
    13 to 21
    How it serves this age group:
    Young adult peers lead it; stops at 21.
  • Children's Grief Center of El Paso
    What it does:
    Free peer grief support groups
    Ages served:
    5 to 18 with parents; 18 to 25
    How it serves this age group:
    Runs a separate peer group for young adults 18 to 25.
Housing and homelessness
Substance use, recovery and peer support
Planning tables and directories
  • El Paso Behavioral Health Consortium
  • findhelp.org
  • Philosophic Systems Institute (PSI)
  • Faith-based institutions
Intercept 1

Law Enforcement and Emergency Services

The moment law enforcement or emergency services respond, and what happens instead of an arrest.

What El Paso County already has 18 resources

No law enforcement or emergency response resource on our list is built for ages 16 to 24.

Crisis response
  • 911 mental health dispatch diversion
  • El Paso Fire Department Mobile Integrated Health
  • El Paso Police Crisis Intervention Team, with EHN clinicians
  • School-based CIT
Intercept 2

Initial Detention and First Court Appearance

What happens between an arrest or referral and the first appearance before a court.

What El Paso County already has 10 resources

Built for ages 16 to 24
  • El Paso Promise, diversion track
    What it does:
    Return to school and job certificates for justice-involved young adults
    Ages served:
    17 to 28 (first phase)
    How it serves this age group:
    County justice staff confirm it is designed for ages 17 to 24.
Diversion
Booking, bail and pretrial
Intercept 3

Jails and Courts

How the courts and the jail recognize and respond to behavioral health needs.

What El Paso County already has 13 resources

No jail or court resource on our list is built for ages 16 to 24. Juvenile courts stop at 17; adult courts treat a 17 year old like any adult.

Juvenile courts
  • 65th District Court, Project HOPE juvenile mental health court
  • 327th District Juvenile Drug Treatment Court
Adult specialty courts
Jail and cross-system work
Intercept 4

Reentry

The return to school, work, housing, and family after detention or jail.

What El Paso County already has 7 resources

Built for ages 16 to 24
Intercept 5

Community Supervision

Probation, parole, and pretrial supervision after a court case.

What El Paso County already has 6 resources

No supervision resource on our list is built for ages 16 to 24. Juvenile probation ends at 17 and adult probation has no young adult caseload.

Funding, grant writing, and technical assistance

El Paso County Transition Age Youth SIM Community Toolkit. Links open in a new tab. Tell your coordinating body if you find one that has moved.

Priority Action Plans

Four teams, four plans, written by the people in the room on workshop day. These are living drafts, not final documents.

Priority 1

Justice and Mental Health Data Sharing

Our priority is to facilitate secure data sharing for improved cross-system collaboration among the justice system and community-based behavioral health service providers.

Team leads: Josue Lachica and Enrique Mata

Objectives and tasks

  • Identify what data is already collected and what is still needed.
  • Decide what a public communications campaign would look like.
    • An education or community awareness project
    • Share examples of successes
  • Identify what tools are used and how data enters each system
  • Identify the largest providers serving the justice-involved population

What the room added

  • HIPAA restrictions
  • Consider legal considerations with data sharing
  • Create standard protocols for what information needs to be shared
  • More inclusive
  • Resource app for individuals looking for resources
  • Punto de Partida
  • Please include Job Corps

Next meeting: Thursday, November 19th at 1:00pm, invitation to follow from priority champions

Printable copy of this plan

A Word version with the objectives, what the room added, and ruled space for notes. Open it in Word or upload it to Google Docs to edit as a team.

Download Word 10 KB
Priority 2

Transitional Liaison for Transition Age Youth

Our priority is to establish a transitional liaison for transition age youth: a trained person who helps young people and their families navigate the youth and adult systems, so fewer young people become involved in those systems and fewer return to them.

Team leads: Eric Martinez, David Ochoa, & Matt Rodriguez

Objectives and tasks

Objectives:

  • Intercept transition age youth from system involvement
  • Reduce recidivism
  • Educate and involve families

Tasks:

  • Identify who is missing
    • School districts (ISDs), through a liaison at each
    • Big Brothers Big Sisters
    • Boys & Girls Club
    • CFD / Pride
    • El Paso Center for Children
    • Center of Hope
    • Juvenile Probation Department (JPD) and other law enforcement
    • Child Protective Services (CPS)
    • UTEP, EPCC, and other colleges
  • Define the liaison role
    • A hybrid peer-to-peer model that draws on Punto and NAMI peer-to-peer training for transition age youth
    • Help navigating life on both sides of the border
    • More support at this age, since young people's brains are still developing
    • Referrals through social media and an app
    • Training for everyone in the system who works with these young people, not only the liaison
  • Narrow down the population and target
    • Support ages 17-18 as they cross from youth to adult systems
      • Specific needs to consider: Federal probation & cultural needs
  • Collect and analyze data
    • How will we know we are successful? Which population are we serving and how will we track results?
  • Build a resource list

What the room added

  • Who should be on the committee?
  • Data committee connection
  • Youth voice
  • Children of incarcerated individuals
  • What percentage of 18 to 24 year olds in CJC have no previous involvement?
    • Use data to guide investment
  • How to prioritize who gets this
  • Where is the funding?
  • TAY liaison certification: NAMI model? Peer to peer
  • Integrate into current peer-to-peer programs
  • Liaisons need to be trained in youth and adult systems
  • Trainings
  • Instructional designers: Amy
  • Develop the workforce, with specific subject matter experts to build capacity
  • Reintegration back into the community
  • Specialty Care WG in FLC

Next meeting: Thursday, November 12th at 9:00am, via Zoom; invitation to follow from priority champions

Printable copy of this plan

A Word version with the objectives, what the room added, and ruled space for notes. Open it in Word or upload it to Google Docs to edit as a team.

Download Word 11 KB
Priority 3

Transitional Housing for Transition Age Youth

Our priority is to expand transitional housing, creating a bridge to a new beginning for TAY: A secure home where TAY are supported by people who understand them and provide the case management and life skills they need to thrive.

Team leads: Adela Alonso, Diane Muñoz, & Amy Wilson

Objectives and tasks

  • Learn from models elsewhere
    • Find communities and states already offering transitional housing for transition age youth
    • Adapt what works to El Paso rather than copying any one model
  • Map what already exists in El Paso
    • List who serves which youth, and each program's eligibility rules (age, custody status, referral source)
    • Start with programs already at the table: Job Corps housing, a grant-funded transitional living program, a youth shelter, and an eight-month apartment program with life skills and case management
    • Gaps named so far
      • Youth who are too young or too old for shelter criteria
      • Not every agency can serve youth under 18
      • Younger teens (14 to 16) should not be housed with older youth
      • Some youth in CPS custody are placed outside the county
      • Job Corps students who finish the program with no stable place to go
  • Define who this effort serves
    • Youth aging out of foster care, including those returning from placements outside the county
    • Justice-involved youth, including youth age 17 finishing juvenile probation who cannot go home
    • Survivors of human trafficking and exploitation
    • Unhoused and runaway youth
    • Youth age 16 and 17 who would otherwise return to unsafe homes
  • Understand the eligibility barriers before pursuing resources
    • Defining a population and then pursuing funding is not enough. First learn what keeps each group of young people out of housing, even before a resource is available, so they can be connected to transitional housing they are actually eligible for
    • Age rules conflict
      • Youth age 16 and 17 are minors for housing purposes
      • Yet a 17-year-old is treated as an adult in the criminal justice system
      • No single funding source cleanly covers one group spanning ages 16 to 24
    • Criminal history brings housing restrictions for young adults with justice involvement
    • For each group of youth, identify the housing options they actually qualify for
  • Bring the right partners to the table
    • Workshop participants who signed up to join this team
    • Agencies that serve each population above, including the agency that supports youth aging out of foster care
    • The community foundation building a provider collaborative for youth before crisis, so the two efforts complement rather than duplicate each other (meeting email forwarded to Enrique Mata)
    • Peer support providers who can help youth see transitional housing as a path forward
    • Stakeholders from the interviews who raised this issue
  • Build one community voice for this need
    • Get more voices into the city's community needs assessment; the last one drew fewer than 700 surveys in a city of nearly 800,000
    • Go to the city together, and invite other organizations to sign on with letters of support
    • Ask that the next funding round include a NOFO (Notice of Funding Opportunity) dedicated to transition age youth housing
    • Get the word out so community members attend public meetings and name this need
  • Pursue funding
    • Seek philanthropic and other unrestricted funding that allows flexible ages, such as 16 through 26
    • Network with funders and major donors
    • Build complete proposals covering case management, apartments, life skills, and basic needs
    • Public dollars are tight: federal rules cap CDBG (Community Development Block Grant) service funding at 15%, and state youth housing funds are small
  • Design housing with support built in
    • Include recovery housing as one part of the overall transitional housing strategy
    • A place youth can call home, where no one will put them out in two weeks
    • Case management that continues until youth reach permanent housing
    • Life skills, including budgeting, insurance, and keeping up a home
    • Furnished apartments with the basics: bed, microwave, utensils, and food
    • Staff who understand that youth will not get it right the first time
    • Youth aging out of foster care often arrive with a case manager already in place
  • Set a target and track results
    • Set a first-year goal for how many young adults to serve (about 50 was suggested)
    • Track the outcomes the team expects: stable housing, youth success, better mental health, and less violence, crime, and drug use

What the room added

  • Bring insurance managed care organizations (MCOs) to the table
  • Bring the El Paso Community Foundation to the table
  • Add recovery housing
  • Partner with the food bank
  • Create peer-to-peer option, peer support
  • Faith-based options
  • Consider Youth home / parent model
  • Make it safe
  • Consider exclusionary barriers, such as criminal history and age
  • Legal ramifications based on age?
  • Focus on overcoming barriers for justice-involved youth
  • Be specific about data
  • Collaborate with the data group

Next meeting: Thursday, December 3rd at 1:30pm via Teams; Adela to send the link

Printable copy of this plan

A Word version with the objectives, what the room added, and ruled space for notes. Open it in Word or upload it to Google Docs to edit as a team.

Download Word 12 KB
Backward mapping handout

A two-page guide to backward mapping: start with one young person at the front door of each kind of housing and work back to the law, funder rule, or agency practice that keeps the door closed. It includes a worked example and steps for building the map as a team.

Download PDF 7 KB
Priority 4

Specialized Docket for Transition Age Youth

Our priority is to raise awareness among judicial and legal partners and to pilot a specialized docket or court.

Team leads: Jamie Bailey, Daniela Jimenez Chisolm, & Catherine Jones

Objectives and tasks

  • Educate key partners about transition age youth
    • Develop CLE (continuing legal education) for attorneys
  • Observe existing specialty courts
    • Organize visits to existing specialty courts (Daniela and Catherine)
  • Design a specialized docket or court
    • Reach out to potential judicial partners (Catherine)
    • Define the scope: misdemeanor or felony, pretrial or probation, and so on
    • Identify potential resources for the docket or court
    • Identify the role of peer support (Jamie)
  • Pilot the new docket or court and collect data
    • Implement the pilot and collect data
    • Pursue funding to expand

What the room added

  • How is “specialized docket” being defined?
  • Need to distinguish between a specialized docket and a specialty court, which is defined at the state level (Ch. 125). Needs a lot of training.
  • Need commitment from all actors to do a specialty court. Start with a specialized docket.
  • You’ll have a broader reach with a specialized docket instead of a court.
  • Ask Judge Reyes to create a specialized docket to manage caseload.
  • Will the Justice Leadership Council (JLC) or an already existing meeting be engaged?
  • Therapeutic jurisprudence is an important concept.
  • Opportunity-based probation is a good model.
  • At truancy court, having crisis providers and specialized staff there is helpful.
  • At what point would a minor show up in court again? Pretrial or post?
  • Got grants to create a mental health court. Does JCMH have funds?
  • Need a voice from the community, an end user.

Next meeting: Friday, November 13th at 9:00am via Zoom; Catherine to send the link

Printable copy of this plan

A Word version with the objectives, what the room added, and ruled space for notes. Open it in Word or upload it to Google Docs to edit as a team.

Download Word 10 KB

El Paso County Transition Age Youth SIM Community Toolkit. Plans as drafted at the workshop. Teams have continued to refine them.

Team Lead Toolkit

Materials for those leading a priority team. Each item below is available to download as it is needed.

PDF Start here

Team Lead Playbook

A visual guide to leading a priority team through the first 90 days, covering what helps teams succeed, how to run effective meetings, and when to raise obstacles.

Download 129 KB
WORD Use first

First Meeting Facilitator Agenda

An agenda for a priority team's first meeting. Copy it, complete the bracketed sections, and adapt it as needed.

Download 10 KB
WORD Every meeting

Meeting Agendas, all four

Four agendas covering the arc of the work: the first meeting, an ongoing check-in, problem-solving, and closing out a goal.

Download 17 KB
EXCEL Between meetings

Progress Tracker

A single place to record each commitment, including the priority, action item, responsible person, due date, and status.

Download 6 KB

Team lead checklist

Your working rhythm between check-ins. Check items off as you go. Your progress saves on this device. Word copy

0 of 19 done

First quarter (months 1 to 3)

Doug and Lynda will check in with your team around month three. Use this quarter to get moving and build a steady rhythm.

Get the team going
Run meetings that move things forward
Track commitments and follow through
Stay connected and surface obstacles
Prepare to share your progress

Second quarter (months 4 to 6)

Through month six.

Hold momentum through month six

Where to find support

Your coordinating body is the first point of contact when a team needs assistance. Several other sources of support are also available.

JCMH Technical Assistance

Technical assistance is available at no cost to communities.
texasjcmh.gov

Coaching with Doug Smith

Individual coaching for team leads and co-leads.
calendly.com/dougsmithmssw

Find a peer county team

Other counties are often working toward similar goals. JCMH or your coordinating body can help make an introduction.

Prepared by Douglas Smith, D-Degree Consulting, and Lynda Frost, Lynfro Consulting.