Hill Country Community Action Association, Inc
Hill Country Community Action Association, Inc.
Release of Information
I give permission to Hill Country Community Action Association, Inc., to share and/or secure any information necessary. I also grant permission to Hill Country Community Action Association, Inc., to contact other individuals or organizations in order to provide services and resources on mine and my household’s behalf.
I understand that this information will be shared or secured on a professional basis only while protecting my right to confidentiality. I am authorizing this agency to contact any person or organization required to process my application and to secure information in my case record, including educational and student records.
I understand that Hill Country Community Action Association, Inc., staff and referral resources will have access to my records.
Household Members age 18 and over:
_____________________________________ _________________________________
Name Relationship to Client
______________________________ _______ _________________________________
Name Relationship to Client
_____________________________________ _________________________________
Name Relationship to Client
_____________________________________ _________________________________
Name Relationship to Client
______________________________ _______ __________________________
Signature of Applicant Date
_________________________________________________ __________________________________
Signature of Case Manager Date
HILL COUNTRY COMMUNITY ACTION ASSOCIATION, INC.
Contractual Agreement
I certify that I agree to comply with the goals and objectives of my case management service plan. These goals and objectives have been designed in detail on this date. I further agree to comply with the following policies and procedures – failure to do so could result in termination from the Case Management Program:
➢ Agree to assigned case manager, who will assist in identifying, setting, and reaching my goals
➢ Agree to work toward my individual plan of action developed through the interview and counseling process, including time frames and tasks with the case manager
➢ Agree to actively participate in vertical mobility activities, as prescribed through my service plan
➢ Agree to submit grades at the end of each semester or quarter
➢ Agree to contact my case manager at least once per month to update my progress via phone, email, or office visit with at least 1 office visit per calendar quarter.
➢ Notify my case manager of any changes in education, vocational, family, or income status
I realize the importance of accomplishing these goals and readily accept the challenges ahead of me.
________________________________ _______________
Participant Signature Date
As a Case Manager for Hill Country Community Action Association, Inc., I agree to and support the participant’s goals.
________________________________ _______________
Case Manager Signature Date
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Self-Sufficiency Client Questionnaire/Screening Questions
Please place a check mark or answer next to the statement that most closely reflects your situation.
*****Highlighted areas are for Case Manager to complete*****
EMPLOYMENT:
1. ___ Full-time work above minimum wage: ___ with benefits ___ without benefits
2. ___ Full-time work at minimum wage: ___ with benefits ___ without benefits
3. ___ Part-time employment: ___with benefits ___ without benefits
4. ___ Unemployed: ___ Have work history or skills ___ Have no work history or skills
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
JOB SKILLS:
1. ___ I have a certification or license from a: ___ 2 yr program ___1 yr program
2. ___ Am presently attending a training program in:______________________________
3. ___ I have on-job training in:_______________________________________________
4. ___ I have been out of the work force for a while. How long? ____________________
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
EDUCATION:
1. ___ College degree: ___ Master’s degree ___Bachelor’s degree ___Associates degree
2. ___ Post-High School credits, vocational or technical education
3. ___ High School diploma or GED certification
4. ___ Reading, writing, and basic math skills are lacking; no HS diploma or GED
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
INCOME:
1. ___ Approximately $_________________/month
2. Credit is: ___ Good ___Poor
3. ___ Need help with money management
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
HOUSING:
1. ___Own my home (pd in full) ___ can pay mortgage ___ cannot afford mortgage ___in foreclosure
2. ___ Rent home or apartment: ___ is what I want ___ is all I can afford
3. ___Subsidized housing: Section 8/Public Housing
4. ___Live with others: ___ is permanent ___ is temporary ___is safe ___ is unsafe
5. ___Living in a shelter: ___ safe, 30 day shelter ___ unsafe shelter
6. ___Homeless
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
FOOD:
1. ___ Sufficient to meet family need
2. ___ Receive federal food benefits
3. ___ Need additional food assistance. ___federal food benefit ___food pantry
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
UTILITIES:
1. ___ Pay entire bill each month
2. ___ Often have carry-over balance on next month’s bill
3. ___ Have a installment payment plan with provider
4. ___ Have large balance on bill and trouble paying it.
5. ___ Have a disconnect notice.
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
Self-Sufficiency Client Questionnaire/Screening Questions
Please place a check mark or answer next to the statement that most closely reflects your situation.
*****Highlighted areas are for Case Manager to complete*****
CHILDCARE:
1. ___ Child enrolled in licensed childcare: ___ I pay all ___ I receive some assistance
2. ___ Child provided childcare by a family member or friend: ___ permanent ___ temporary
3. ___ Child enrolled in unregulated or unlicensed childcare facility
4. ___ Child on waiting list for enrollment in childcare
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
TRANSPORTATION:
1. ___ I own my own car/can make car payment: Make____________ Model___________ Yr________
2. ___ I have transportation needs met through public transportation
3. ___ I sometimes have transportation needs met through public transportation
4. ___ I rarely have public transportation
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
HEALTH INSURANCE:
1. ___ Have health insurance
2. ___ Enrolled in Medicare and/or Supplemental Insurance
3. ___ Enrolled in the Affordable Care Act
4. ___ No health insurance
Need to stabilize? ___Yes ___No Referrals Made (list):___________________________________
Most recent job?_______________________________________________________________
Reason for leaving job?_________________________________________________________
Volunteer work?_______________________________________________________________
Strengths?___________________________________________________________________
Weaknesses?_________________________________________________________________
Education Goals?______________________________________________________________
Employment Goals?____________________________________________________________
What are some goals you have accomplished?_______________________________________
____________________________________________________________________________
Motivation for setting goals and taking the necessary steps to achieve those goals?__________
____________________________________________________________________________
____________________________________________________________________________
Explain why you would be a good addition to our Case Management Program.
_____________________________________________________________________________
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