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

 

Email

 

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

M

F

Have you ever been incarcerated?

 

Yes

No

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

No

Workshop Date:

 

How did you hear about Next Steps?

 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Have you gone to other organizations for help?

Yes

No

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

 

No

 

Are you registered to vote?

 

Yes

 

No

 

Proof of Residence:

 

 

 

Comments:

 

 
 
 

 

Income

 

 

Please circle your sources of income.

Do you have any income?

 

Yes

 

No

 

 

 

 

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

 

No

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

 

Yes

 

No

Are you interested in working on money management or budgeting?

 

Yes

 

No

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

 

No

 

Date of Birth

 

 

Circle Race

 

Black

 

Hispanic

 

White

 

Asian

 

Native American

 

Middle Eastern

 

Other

Circle Gender

 

Male

 

Female

Disabled?

 

Yes

 

No

 

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

 

Name of school attending

 

_______________________________________________________

Has medical insurance?

 

 

Yes

 

 

No

Has been immunized?

 

 

Yes

 

 

No

                                                                                                     

Circle Relationship #2

 

Your child

 

Someone else’s child

 

Your spouse

 

Other member of your family

 

Other adult

 

First Name

 

 

Last Name

 

Cohabitant

 

Yes

 

No

 

Date of Birth

 

 

Circle Race

 

Black

 

Hispanic

 

White

 

Asian

 

Native American

 

Middle Eastern

 

Other

Circle Gender

 

Male

 

Female

Disabled?

 

Yes

 

No

 

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

 

Name of school attending

 

_______________________________________________________

Has medical insurance?

 

 

Yes

 

 

No

Has been immunized?

 

 

Yes

 

 

No

                                             

Circle Relationship #3

 

Your child

 

Someone else’s child

 

Your spouse

 

Other member of your family

 

Other adult

 

First Name

 

 

Last Name

 

Cohabitant

 

Yes

 

No

 

Date of Birth

 

 

Circle Race

 

Black

 

Hispanic

 

White

 

Asian

 

Native American

 

Middle Eastern

 

Other

Circle Gender

 

Male

 

Female

Disabled?

 

Yes

 

No

 

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

 

Name of school attending

 

_______________________________________________________

Has medical insurance?

 

 

Yes

 

 

No

Has been immunized?

 

 

Yes

 

 

No

                                             

Circle Relationship #4

 

Your child

 

Someone else’s child

 

Your spouse

 

Other member of your family

 

Other adult

 

First Name

 

 

Last Name

 

Cohabitant

 

Yes

 

No

 

Date of Birth

 

 

Circle Race

 

Black

 

Hispanic

 

White

 

Asian

 

Native American

 

Middle Eastern

 

Other

Circle Gender

 

Male

 

Female

Disabled?

 

Yes

 

No

 

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

 

Name of school attending

 

_______________________________________________________

Has medical insurance?

 

 

Yes

 

 

No

Has been immunized?

 

 

Yes

 

 

No

                                             

Do you have other family in the area?

 

Yes

 

No

Do you have contact with them?

 

Yes

 

No

 

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

No

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

No

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

No

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

Yes

No

Do you have appropriate clothing for interviews?

Yes

No

Do you have a current/updated resume?

Yes

No

Do you have access to your resume?

Yes

No

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.

1

Job title

 

Company name

 

 

City, State

 

Dates employed

 

to

 

 

 

Month and year

 

Month and year

 

Duties/responsibilities

 

 

 

 

Reason for leaving

 

2

Job title

 

Company name

 

 

City, State

 

Dates employed

 

to

 

 

 

Month and year

 

Month and year

 

Duties/responsibilities

 

 

 

 

Reason for leaving

 

3

Job title

 

Company name

 

 

City, State

 

Dates employed

 

to

 

 

 

Month and year

 

Month and year

 

Duties/responsibilities

 

 

 

 

Reason for leaving

 

4

Job title

 

Company name

 

 

City, State

 

Dates employed

 

to

 

 

 

Month and year

 

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)