PCSI Client Intake Packet-Training Department
Pittsburgh Community Services, Inc. (PCSI) was established in 1983 as the designated Community Action Agency (CAA) for the city of Pittsburgh and has served as the anti-poverty agency for the city for over 30 years. PCSI serves approximately 6,000 individuals annually. Below you will find our electronic enrollment for services with Pittsburgh Community Services. All items with a red star must be completed.
Is this your first time working with Pittsburgh Community Services, Inc.?
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Yes
No
Were you referred to Pittsburgh Community Services?
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Yes
No
Who was your referral source?
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PCSI Staff Member
PA CareerLink
Facebook/ Social Media Flyer
Partner4work
None
Which office is more convenient for you?
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Oakland-249 N. Craig St.
Southside-50 S. 7th St.
Contact Information
Please complete all fields
Today's Date
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Name
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First Name
Last Name
Birth Date
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E-mail
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Contact Phone
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-
Area Code
Phone Number
Is this a cell phone?
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Yes
No
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Is your address located in the City of Pittsburgh?
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Yes
No
Unsure
What Neighborhood do you live in?
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Please Check the following that apply to you:
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Registered with PA CareerLink
I am a Veteran
I live in Subsidized Housing
Currently Employed
Been Laid off
Have a Driver's License
Check all Services that you are interested in receiving from PCSI:
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Resume/Cover Letter Help
Job Leads & HR Referrals
Planning & Organizing a job search
Help Finding a Better job
Business Start Up Help
Career Exploration Help
Earning a GED
Community Service/Internship
Credit Repair/Financial/Home Buying
Obtaining a Driver's License
Certification in Food Service/Serv Safe
Certification in Construction-OSHA Flagger
Customer Service Certifcation
Medical Office/Health Adminstation Certification
Social & Human Services Associate Certification
Criminal Background?
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Yes
No
If yes, charges?
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Are you on probation or parole?
Yes
No
What area of employment are you interested in? (Check all that apply):
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Clerical
CDL Driver
Child Care
Construction
Data Entry
Food Service
Medical Office
Supervisory
Factory
Retail
Teacher/Aide
Social Work
Production
Driver
Sales
Customer Service
Telemarketer
Healthcare/Nursing/HHA
Warehouse
Manufacturing
Maintenance/Housekeeping
Laborer
Banking
Work Experience 1:
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Work Experience 2:
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Work Experience 3:
Customer Assessment
Please complete the following questions to help PCSI assess your needs.
Check all documents that can be provided:
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Social Security Card
Driver's License/Photo ID
Proof of Residency
Social Security Determination Letter
Pay Stubs
Department of Human Services Benefits Letter
Unemployment Benefits Letter
Pension
Family Dynamics
Marital Status:
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Single
Live with Partner
Married
Separated
Divorced
Widowed
Please list who lives in your home (include age and relationship)
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Grade Levels of Children Living in the home
0-5yrs old
1st-8th Grade
9th-12th Grade
Are there any concerns regarding your children?
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Child Care
Achieving a basic grade level
Demonstrates positive approach toward learning
Children are nurtured
Appropriate books and other learning materials
Not Applicable
Describe your home environment:
Free of violence
Basic Needs Met
Who Supports you?(financially, emotionally, etc.)
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Housing
Describe your housing situation:
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Rent
Temporary Housing
Homeless
Other Permanent Housing
Own
Do you want to leave your current residence?
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Yes
No
If yes, explain:
Health and Well Being
Describe your Mental Health Care:
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Have a diagnosis
Been Hospitalized
Received Outpatient care
Take Medication
Does not apply
Check all that apply, in the last month have you?
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Felt tired for no reason
Felt nervous for no reason
Felt hopeless
Felt restless or fidgety
Felt worthless
Felt like nothing could cheer you up
Felt Depressed
Does not apply
Do you have children with mental health concerns? If yes, please explain.
Are you a veteran?
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Yes
No
Dates of Service:
When was the last time you visited a doctor and/or dentist?
Do you require any of the following?
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Not Applicable
Wheelchair
Walker
Crutchers
What are your main health concerns?
Do you have health insurance?
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None
Other
Direct Purchase
State Children
Military
State Adult
Medicare
Employment Based
Medicaid
Substance Abuse and/or Treatment?
Yes
No
Do you have any chronic health concerns?
Yes
No
Education
Highest Level of Education
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GED
High School Diploma
Technical College
Some College
College Degree
Graduate/Post Secondary
List any special learning needs:
List any special training or skills:
Describe your employment situation:
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Employed Full Time
Employed Part Time
Laid Off
Entrepreneur
Employment
Are you currently employed?
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Yes
No
What are your long term employment goals?
What is your transportation situation?
Own a vehicle
Has daily access to a vehicle
Public transportation (Bus)
Supports
Do you receive any form of Income? (check all that apply)
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No income at this time.
Employment Wages
Public Assistance, Social Security or SSI
Child Support, Alimony or regular monetary gift from family friends
Assets: Stocks, Inherited property
Interest income from savings, checking, Christmas club, money market etc.
U.S.Saving Bonds, Stocks or Bonds
Pension, annuities, retirement funds, etc.
Real Estate Property, earned income tax credit, etc.
Other income, property sold, babysitting, tips, etc.
Non Income Affidavit: I do hereby swear and affirm that I do not have any source of income. This includes but is not limited to income from any of the following: 1.Wages, Public Assistance (ADC, GR etc.) Social Security, SSI etc.: 2. Child Support, Alimony or regular monetary gifts from family, friends, ets: 3. Assets (Homes, stocks etc. may be inherited property); 4. Interest income from savings, checking, Christmas club and other bank accounts, IRA’s, Certificates of Deposit, Money Market Funds, Credit Unions,etc.; 5. U.S. Savings Bonds, Stocks or Bonds of any kind; 6. Pensions, annuities, retirement funds, etc. (this includes benefits you may receive from being beneficiary of a lift insurance or retirement plan;) 7. Real Estate Property, Earned Income Tax Credit, etc.; 8. ANY OTHER INCOME (includes tips, property sold, babysitting etc. “
Clear
Check all services needed:
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Budgeting
Supportive Services(Photo ID, Furniture, etc.)
Food
GED
Support groups(Parenting, Counseling, etc)
Childcare
Transportation
Healthcare
Employment
Education
Referral to resources
Housing
Please upload 2 forms of identification here. These forms could include: Social Security Card, Passport, Birth Certificate, State ID, Driver License.
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Browse Files
Cancel
of
Signatures
Participation Agreement: Pittsburgh Community Services, Inc. is offering Development Series Workshops to all eligible PCSI customers if you have received one of the following services: Food Assistance, Utility Assistance, Work Ready Program, Workforce Development & Training, and/or housing listing distribution. To remain eligible for PCSI services you must remain in good standing with regular attendance to participate in workshops and other various programs directed by PCSI. You will be strongly encouraged to attend 2 workshops. The workshops will be held bi-monthly at 249 N. Craig Street,Pittsburgh, PA 15213. Your signature denotes agreement to be contacted by PCSI staff members with dates and class schedules. Participant/PCSI Acknowledgement
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Clear
PHOTOGRAPHIC& VIDEO RELEASE FORM The undersigned hereby gives permission to Pittsburgh Community Services Incorporated (PCSI) to capture and use a photographic and or video like of myself for purposes related to program advertisement, news copy, web site photos, agency reporting, and recruiting of participants eligible for the services offered by PCSI, or authorized by PCSI for similar purposes within their domain and under their complete control. My image(s) may not be used for commercial gain without my specific written consent. My image(s) and or likeness may be used in and on program brochures and or advertisements designed to attract capital investment in PCSI programs and projects, or to win funding from contributors,donors and or foundations grantors. My permission may be revoked at any time by giving written notice to the undersigned PCSI staffer or the agency’s Chief Program Director. Signature:
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1. PCSI wants everyone receiving their programs and/or services to be satisfied. If for some reason a customer is not satisfied with a program and/or service received from PCSI; they will be requested to document their complaint in writing. They will need to identify their initial interest in the program and/or service and detail their related concern with the staff associated with that program. If their complaint cannot be resolved with the program staff, they may request a meeting with the Chief Program Director. 2. The Chief Program Director will meet with the customer and program staff to discuss the complaint. The Chief Program Director will review all necessary information and make every attempt to resolve the situation. If the customer was referred by another source, that source will be contacted if necessary. If the issue is resolved, the customer must sign documentation that states that they agree to the continuation of services. If the issue is not resolved, the customer may request to meet with the Executive Director. 3. If it is decided that PCSI is not the appropriate agency for services, the customer will be referred to external resources.
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Submit for Eligibility
Should be Empty: