PCSI Training Department Intake Packet

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.? *

Yes No
Were you referred to Pittsburgh Community Services? *
Who was your referral source? *

PCSI Staff Member PA CareerLink GoodWill Partner4work None
Which office is more convenient for you? *

Oakland-249 N. Craig St. Southside-50 S. 7th St.
Contact Information

Please complete all fields
Today's Date *
Name *

First Name Last Name
Birth Date *

Month Day Year
E-mail *
Contact Phone *

Area Code Phone Number
Is this a cell phone? *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Is your address located in the City of Pittsburgh? *

Yes No Unsure
What Neighborhood do you live in? *
Please Check the following that apply to you: *

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: *

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? *
If yes, charges? *
Are you on probation or parole?

Yes No
What area of employment are you interested in? (Check all that apply): *

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: *
Work Experience 2: *
Work Experience 3:
Customer Assessment

Please complete the following questions to help PCSI assess your needs.
Check all documents that can be provided: *

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: *

Single Live with Partner Married Separated Divorced Widowed
Please list who lives in your home (include age and relationship) *
Grade Levels of Children Living in the home

0-5yrs old 1st-8th Grade 9th-12th Grade
Are there any concerns regarding your children? *

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.) *
Housing
Describe your housing situation: *

Rent Temporary Housing Homeless Other Permanent Housing Own
Do you want to leave your current residence? *

Yes No
If yes, explain:
Health and Well Being
Describe your Mental Health Care: *

Have a diagnosis Been Hospitalized Received Outpatient care Take Medication Does not apply
Check all that apply, in the last month have you? *

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? *

Yes No
Dates of Service:
When was the last time you visited a doctor and/or dentist?
Do you require any of the following? *

Not Applicable Wheelchair Walker Crutchers
What are your main health concerns?
Do you have health insurance? *

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 *

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: *

Employed Full Time Employed Part Time Laid Off Entrepreneur
Employment
Are you currently employed? *

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) *

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: *

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. *

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 *

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: *
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. *
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

PCSI Client Intake Packet-Training Department

Contact Information

Customer Assessment

Family Dynamics

Housing

Health and Well Being

Education

Employment

Supports

Signatures