Community Partnership Questionnaire

Community Partnership Questionnaire

CSBG
Yellowstone Country Assistance Network, a non-profit focused on aiding low-income clients in Park and Hot Springs County, invites local agencies to become community partners. By completing our questionnaire and signing the Community Partnership Agreement, partners can access a secure portal for processing aid applications.

We are currently updating our community needs assessment, so some questions are specific to help us determine available community resources.
The Name of Your Organization
Primary Contact Name

First NameLast Name
Primary Contact Email
example@example.com
This is the address where clients will come for appointments to complete applications with your staff.
Organization Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Days and Hours of Operation at location 1 (for customers to apply, or put by appointment only)
Secondary Location if Applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Days and Hours of Operation at location 2 (for customers to apply, or put by appointment only)
Location 2 Phone Number (if not the same as location 1)
Please enter a valid phone number.Format: (000) 000-0000.
Your Organization's Website Address
Tell us about your services
What kinds of case management services does your organization offer?

Other
Approximately how many low-income clients, defined as those at or below 200% of the Federal Poverty Level, does your organization serve each year?
What kind of services does your organization offer to support low-income individuals and families?
Looking to the future what financial assistance services can YCAN offer to your low-income clients that they currently do not have access to?
What is the average duration of a client's enrollment in your case management services or program?

Other
What is the typical frequency with which your average client seeks financial assistance from community organizations within a year?

Other
Does your organization have any funding sources to provide direct financial assistance services to low-income individuals?
If yes, what services can you provided and what is the approximate budget?
Service Agreement
We kindly request a list of your case workers, including their names, phone numbers, and email addresses, who will be referring to this program.
Date

MonthDayYear
Date
Should be Empty:

Community Partnership Questionnaire

Tell us about your services

Service Agreement