Next Steps of South Carolina - Next Step Program Registration & Intake Form

Next Steps of South Carolina

Registration and Intake Form

Why are we asking you for this information?

This form provides casework staff with enough information to understand your needs.

Please answer as many questions as you can—honestly and to the best of your ability.

You are not required to answer all questions to participate in our program. No information you provide will prevent you from participating. But . . . answering as many questions as possible will help us work with you better.

Any information you provide is strictly confidential. It cannot be shared with anyone outside of the Next Step Program without your written consent.

Samaritan Mentor: ________________________________________________

Introduction

Name

Today’s date:

First

Middle

Last

Birth date

SSN

Address

City

State

Zip

Phone numbers

Home

Cell

Work

If no phone, where may we leave a message for you?

Which of these describes your initial living situation? (please circle one)

Living with friends or family

Homeless—street

Homeless—shelter

Homeless—transitional

Homeless—halfway house

Homeless—other

Own

Other–not homeless

Rent/ lease

Which of these describes your current living situation? (please circle one)

Living with friends or family

Homeless—street

Homeless—shelter

Homeless—transitional

Homeless—halfway house

Homeless—other

Own

Other–not homeless

Rent/ lease

If other, describe:

Gender

Have you ever been incarcerated?

Yes

Race

Black

Hispanic

White

Asian

Native American

Middle Eastern

Other

Family Status

Please circle your answers

Circle your status. (Circle all that apply.)

Single

Couple

Married

Divorced

Separated

Widowed

Originating Affiliate: _________________________________________________

Registration Date: __________________________

Off-Site Workshop?

Yes

Workshop Date:

How did you hear about Next Steps?

______________________________________________________________________________

Have you gone to other organizations for help?

Yes

If yes, which ones?

The Next Step Program works with people who want to take steps toward a better life.

What changes would you like to make to improve your life?

Why did you come to Next Steps?

Comments:

Identification

Please circle each type of identification you have

What identification do you have? (Circle all that apply.)

Birth certificate

Food stamp ID

Green card

Driver’s license

Non-driver’s license

Social Security card

Passport

Other ID:

_______________________________________________________________

May we take your photograph?

Yes

Are you registered to vote?

Yes

Proof of Residence:

Comments:

Income

Please circle your sources of income.

Do you have any income?

Yes

If yes, from what source? (Circle all that apply.)

General Relief

TANF

SSI

SSDI

Social Security

Work/Employment Job#1

Work/employment Job#2

Unemployment

Child support

Housing grant

Food stamps

Other_________________

Total Monthly Income:

_______________________________________

Have you applied for public benefits for which you might be eligible?

Yes

Can your income cover basic needs—housing, food, clothing and transportation?

Yes

Are you interested in working on money management or budgeting?

Yes

When was the last time you had a credit report?

Comments:

Family Status

Please circle your answers

Circle your status (Circle all that apply)

Single

Couple

Married

Divorced

Separated

Widowed

For each of the people living with you, please provide the following information:

Circle Relationship #1

Your child

Someone else’s child

Your spouse

Other member of your family

Other adult

First Name

Last Name

Cohabitant

Yes

Date of Birth

Circle Race

Black

Hispanic

White

Asian

Native American

Middle Eastern

Other

Circle Gender

Male

Female

Disabled?

Yes

The following questions apply ONLY if this is your child living with you:

Name of school attending

_______________________________________________________

Has medical insurance?

Yes

Has been immunized?

Yes

Circle Relationship #2

Your child

Someone else’s child

Your spouse

Other member of your family

Other adult

First Name

Last Name

Cohabitant

Yes

Date of Birth

Circle Race

Black

Hispanic

White

Asian

Native American

Middle Eastern

Other

Circle Gender

Male

Female

Disabled?

Yes

The following questions apply ONLY if this is your child living with you:

Name of school attending

_______________________________________________________

Has medical insurance?

Yes

Has been immunized?

Yes

Circle Relationship #3

Your child

Someone else’s child

Your spouse

Other member of your family

Other adult

First Name

Last Name

Cohabitant

Yes

Date of Birth

Circle Race

Black

Hispanic

White

Asian

Native American

Middle Eastern

Other

Circle Gender

Male

Female

Disabled?

Yes

The following questions apply ONLY if this is your child living with you:

Name of school attending

_______________________________________________________

Has medical insurance?

Yes

Has been immunized?

Yes

Circle Relationship #4

Your child

Someone else’s child

Your spouse

Other member of your family

Other adult

First Name

Last Name

Cohabitant

Yes

Date of Birth

Circle Race

Black

Hispanic

White

Asian

Native American

Middle Eastern

Other

Circle Gender

Male

Female

Disabled?

Yes

The following questions apply ONLY if this is your child living with you:

Name of school attending

_______________________________________________________

Has medical insurance?

Yes

Has been immunized?

Yes

Do you have other family in the area?

Yes

Do you have contact with them?

Yes

Comments:



Alcohol/Drug Information			Please circle your answers. Please be honest.Remember, this information is confidential.

Yes	No	Do you use drugs now and then?
Yes	No	Do you enjoy a drink now and then?
Yes	No	Do you have a substance abuse problem?
Yes	No	Are you in recovery?Sobriety Date: ______________________
•••
Yes	No	Do any family or friends worry or complain about your drinking?
Yes	No	Have you ever attended AA (Alcoholics Anonymous) meetings?
Yes	No	Have you ever lost a job because of drinking?
Yes	No	Have you ever sought help from a doctor, clergy person, social worker, psychiatrist or another person because of drinking?
Yes	No	Have you ever been arrested for driving and alcohol related issues?
Yes	No	Have you ever been arrested, or taken into custody, because of drunken behavior?
•••
Yes	No	Do any friends or family worry or complain about your drug use?
Yes	No	Have you ever lost a job because of drugs?
Yes	No	Have you ever attended NA (Narcotics Anonymous) meetings?
Yes	No	Have you ever sought help from a doctor, clergy person, social worker, psychiatrist or another person because of drug related issues?
Yes	No	Have you ever been arrested or taken into custody because of drug related issues?
•••
Yes	No	Have you ever gone to treatment for a drug or alcohol addiction?
Yes	No	Have you ever completed a treatment program?
Yes	No	Do you regularly attend AA or NA meetings?
Yes	No	Do you have supportive friends, family members, or sponsors who encourage you to stay clean and sober?
Comments:



Medical				Please circle your answers
				.
Yes	No	Do you have health insurance?If yes, what type?
Yes	No	Do you have any physical disability?If yes, what?
Yes	No	Do you have regular physicals?Date of last physical:
Yes	No	Are you currently receiving medical care? If yes, for what?

Yes	No	Are you currently receiving counseling or therapy for any mental health issues?
Yes	No	Do you have a history of mental illness?
Yes	No	Do you have a history of depression?
Yes	No	Are you taking medication for any mental health issues?
Yes	No	Have you ever received a diagnosis for a mental health illness? If yes, what type?

Yes	No	Have you ever been in an abusive relationship, physical or emotional?
Comments:

Education

Please circle your answers

Do you have a high school diploma or GED?

Yes

If no, highest grade completed?

Where did you attend high school?

Name of school

City and state

Do you have any other degrees or certifications?

Employment

Please circle your answers

Yes

Are you seeking or wish to seek employment at this time? If no, you may skip the rest of this section.

What types of jobs are you looking for?In what field(s)?

Yes

Do you have sufficient skills to find a job in your field without further training?

Yes

Do you have appropriate clothing for interviews?

Yes

Do you have a current/updated resume?

Yes

Do you have access to your resume?

Yes

Do you have a copy of your resume (circle one)on paperon disk

If you do not have a current resume, please fill out your work history below.

Work history

Please list most recent job first.

Job title

Company name

City, State

Dates employed

Month and year

Duties/responsibilities

Reason for leaving

Job title

Company name

City, State

Dates employed

Month and year

Duties/responsibilities

Reason for leaving

Job title

Company name

City, State

Dates employed

Month and year

Duties/responsibilities

Reason for leaving

Job title

Company name

City, State

Dates employed

Month and year

Duties/responsibilities

Reason for leaving

Of all of your jobs, which one did you like the best?

Why?

List types of skills you have from these jobs, e.g. operating machinery, cashiering, computer skills:

Contacts

Who may we contact in an emergency?
	Contact Name				Relationship

	Home Phone		Cell Phone		Work Phone

	Contact Address

	Contact Email
Who else may we contact in an emergency?
	Contact Name				Relationship

	Home Phone		Cell Phone		Work Phone

	Contact Address

	Contact Email
Who may we contact for follow up?
	Contact Name					Relationship

	Home Phone	Cell Phone		Work Phone

	Contact Address

	Contact Email
Who else may we contact for follow up?
	Contact Name					Relationship

	Home Phone	Cell Phone		Work Phone

	Contact Address

	Contact Email
Special Contact Instructions:



Comments:

What are some changes that you would like to make in your life?

PLEASE READ AND FOLLOW THESE NOTES

Goals Please use one of the 60 Goals within the five categories in the Charity Tracker Plus Database: (1) Basic Needs, (2) Basic Skills, (3) Increase Income, (4) Gain and Sustain Assets, and (5) Health. If all of these fail to describe the Participant's Goal, create a New Goal within one of the five goal categories in the Database. As you record the Goal, please include the alpha-numeric designation, e.g., "A3" AND the full name of the Goal, e.g., "Complete the Benefit Bank Application".

Next Steps Please use short action-oriented phrases with VERBS to define each “next step”, e.g., “CALL Telephone Number”, “MAKE Appointment” or “GO TO Facility/Agency ABC” This will make it easier to measure outcomes through reports for the Affiliate’s management and grant-writing purposes.

Status There are 10 status categories within the Charity Tracker Plus database: (1) No Status, (2) Currently Participating, (3) Did Not Complete, (4) Did Not Qualify, (5) Enrolled), (6)Pending, (7) Received Assistance, (8) Waiting List, (9) Complete, and (10) Not Applicable. Please select and write one of them. If this is the FIRST Next Step within a Goal, please select "No Status". As a Participant delves deeper and deeper into his/her Next Steps within this Goal, you can select from among the other statuses.

Due Date Please select and write a date based on the best guess, e.g., 1-week, 2-weeks, 3-weeks, etc. by which you and the Participant believe s/he can complete this Next Step.

Notes Please explain why you are sending the Participant to this employment or social service resource organization.

Email Notification 5-Days before the Due Date of each Next Step, the Samaritan Mentor will receive an email about the upcoming action date for the Next Step. The Samaritan Mentor should please call the Participant to remind him/her to take that Next Step.

Goal:

Status:

Due Date:

Next Step:

Notes:

Goal:

Status:

Due Date:

Next Step:

Notes:

Goal:

Status:

Due Date:

Next Step:

Notes:

Goal:

Status:

Due Date:

Next Step:

Notes:

Goal:

Status:

Due Date:

Next Step:

Notes:

Goal:

Status:

Due Date:

Next Step:

Notes:

Goal:

Status:

Due Date:

Next Step:

Notes:

Next Steps of South Carolina is indebted to Samaritan Ministry of Greater Washington (www.samaritanministry.org ), Lazarus Ministry of Christ Episcopal Church, Alexandria, VA (www.historicchristchurch.org), and The Cooperative Ministry, Columbia, SC (www.coopmin.org) for allowing us to pattern our Next Step Program after their successful ministries.

(Last modified 7/14/2017)