Old 2022 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.?*

YesNo
Were you referred to Pittsburgh Community Services?*
Who was your referral source?*

PCSI Staff MemberPA CareerLinkFacebook/ Social Media FlyerPartner4workNone
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?*

YesNoUnsure
What Neighborhood do you live in?*
Please Check the following that apply to you:*

Registered with PA CareerLinkI am a VeteranI live in Subsidized HousingCurrently EmployedBeen Laid offHave a Driver's License
Check all Services that you are interested in receiving from PCSI:*

Resume/Cover Letter HelpJob Leads & HR ReferralsPlanning & Organizing a job searchHelp Finding a Better jobBusiness Start Up HelpCareer Exploration HelpEarning a GEDCommunity Service/InternshipCredit Repair/Financial/Home BuyingObtaining a Driver's LicenseCertification in Food Service/Serv SafeCertification in Construction-OSHA FlaggerCustomer Service CertifcationMedical Office/Health Adminstation CertificationSocial & Human Services Associate Certification
Criminal Background?*
If yes, charges?*
Are you on probation or parole?

YesNo
What area of employment are you interested in? (Check all that apply):*

ClericalCDL DriverChild CareConstructionData EntryFood ServiceMedical OfficeSupervisoryFactoryRetailTeacher/AideSocial WorkProductionDriverSalesCustomer ServiceTelemarketerHealthcare/Nursing/HHAWarehouseManufacturingMaintenance/HousekeepingLaborerBanking
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 CardDriver's License/Photo IDProof of ResidencySocial Security Determination LetterPay StubsDepartment of Human Services Benefits LetterUnemployment Benefits LetterPension
Family Dynamics
Marital Status:*

SingleLive with PartnerMarriedSeparatedDivorcedWidowed
Please list who lives in your home (include age and relationship)*
Grade Levels of Children Living in the home

0-5yrs old1st-8th Grade9th-12th Grade
Are there any concerns regarding your children?*

Child CareAchieving a basic grade levelDemonstrates positive approach toward learningChildren are nurturedAppropriate books and other learning materialsNot Applicable
Describe your home environment:

Free of violenceBasic Needs Met
Who Supports you?(financially, emotionally, etc.)*
Housing
Describe your housing situation:*

RentTemporary HousingHomelessOther Permanent HousingOwn
Do you want to leave your current residence?*

YesNo
If yes, explain:
Health and Well Being
Describe your Mental Health Care:*

Have a diagnosisBeen HospitalizedReceived Outpatient careTake MedicationDoes not apply
Check all that apply, in the last month have you?*

Felt tired for no reasonFelt nervous for no reasonFelt hopelessFelt restless or fidgetyFelt worthlessFelt like nothing could cheer you upFelt DepressedDoes not apply
Do you have children with mental health concerns? If yes, please explain.
Are you a veteran?*

YesNo
Dates of Service:
When was the last time you visited a doctor and/or dentist?
Do you require any of the following?*

Not ApplicableWheelchairWalkerCrutchers
What are your main health concerns?
Do you have health insurance?*

NoneOtherDirect PurchaseState ChildrenMilitaryState AdultMedicareEmployment BasedMedicaid
Substance Abuse and/or Treatment?

YesNo
Do you have any chronic health concerns?

YesNo
Education
Highest Level of Education*

GEDHigh School DiplomaTechnical CollegeSome CollegeCollege DegreeGraduate/Post Secondary
List any special learning needs:
List any special training or skills:
Describe your employment situation:*

Employed Full TimeEmployed Part TimeLaid OffEntrepreneur
Employment
Are you currently employed?*

YesNo
What are your long term employment goals?
What is your transportation situation?

Own a vehicleHas daily access to a vehiclePublic transportation (Bus)
Supports
Do you receive any form of Income? (check all that apply)*

No income at this time.Employment WagesPublic Assistance, Social Security or SSIChild Support, Alimony or regular monetary gift from family friendsAssets: Stocks, Inherited propertyInterest income from savings, checking, Christmas club, money market etc.U.S.Saving Bonds, Stocks or BondsPension, 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. “

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Check all services needed:*

BudgetingSupportive Services(Photo ID, Furniture, etc.)FoodGEDSupport groups(Parenting, Counseling, etc)ChildcareTransportationHealthcareEmploymentEducationReferral to resourcesHousing
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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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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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.*
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PCSI Client Intake Packet-Training Department

Contact Information

Customer Assessment

Family Dynamics

Housing

Health and Well Being

Education

Employment

Supports

Signatures