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:

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Name Relationship to Client

______________________________ _______ _________________________________

Name Relationship to Client

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Name Relationship to Client

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Name Relationship to Client

______________________________ _______ __________________________

Signature of Applicant Date

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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.

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Participant Signature Date

As a Case Manager for Hill Country Community Action Association, Inc., I agree to and support the participant’s goals.

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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?_______________________________________

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Motivation for setting goals and taking the necessary steps to achieve those goals?__________

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Explain why you would be a good addition to our Case Management Program.

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