Triangle, Inc. DTA Intake Form

DTA Intake Meeting Checklist
Intake Paperwork
1. DTA Participant Information Form *Mandatory
2. DTA Program Participation Guidelines: to establish a supportive and professional relationship with clients. *Mandatory
3. Release of Information: by signing this form permission is granted by the client for Triangle to discuss agreed upon topics with agreed upon people designated by the client.
4. Authorization for Emergency Medical Treatment: by signing this form you are giving Triangle permission to perform First Aid and or obtain medical assistance is the case of an emergency. *Mandatory
5. Employment Disclosure Release: this form gives Triangle permission to discuss your needs and capabilities with potential employers.
6. Background Check Paperwork/CORI form: optional for clients supported by Triangle.
Optional Tools
1. Media Consent: this form will allow Triangle to promote its programming by highlighting your success.
Name of Employment Specialist:
Signature

Clear
Date

MonthDayYear
Date
Email address (if you'd like to receive a copy of this form)
example@example.com
Please complete the forms below by clicking the arrow next to each one. You can preview the completed form, save the form to finish later, or submit the form using the buttons at the bottom.

Triangle, Inc. DTA Program Participation Guidelines (Required)
To establish a supportive and professional relationship with clients. Please note: your Employment Specialist will discuss these guidelines with you as well.

*Mandatory
Triangle’s goal is to help our clients reach their vocational goals. Below are guidelines that will help us in supporting you to achieve your goals.

A client will:
- call back withing 48 hours of message or text being sent by provider staff
- follow up on assignments or call provider staff for support if needed
- call provider staff if you are unsure when you next meeting is
- answer the phone for phone meetings ready to talk with undivided attention
  - if more than 15 minutes late for a meeting (by phone, in person, or virtual) it will be cancelled and rescheduled.
- keep an open line of communication between meetings and throughout the duration of our work together
Triangle staff will:
- keep client information confidential
- adhere to the same guidelines around participation
- keep relationships professional
Signature*

Clear
Your signature indicates receipt and acknowledgement of the above guidelines.
Date*

MonthDayYear
Date

Release of Information
By signing this form, permission is granted by the client for Triangle to discuss agreed upon topics with agreed upon people designated by the client.
I, First Name Last Name give my permission to Triangle, Inc. to release the
Information listed below to Person Name #1 and Person Name #2 of Agency Name/Relation #1 Agency/Relation Address #1 and Agency Name/Relation #2 Agency/Relation Address #2 for the purpose of:
Specific information proposed for release:
Manner in which information will be transmitted (e.g. verbal, written, fax, etc.):
I understand that this release is valid only for the period of one year from the date of my signature and that I may withdraw my consent at any time. The information to be released has been explained to me and I have had the opportunity to ask questions.
Signature of individual authorizing release

Clear
Date

MonthDayYear
Date

Authorization for Emergency Medical Treatment (Required)
By signing this form, you are giving Triangle permission to perform First Aid and or obtain medical assistance is the case of an emergency.

*Mandatory
I, First Name Last Name give Triangle, Inc. my permission to perform First Aid and or obtain medical assistance in the event that I am injured or become ill.
Individual's Signature*

Clear
Date*

MonthDayYear
Date
Guardian's Signature (if necessary)

Clear
Date

MonthDayYear
Date

Employer Disclosure Release
This form gives Triangle permission to discuss your needs and capabilities with potential employers. Please sign either section A or section B.
Section A:
I, First Name Last Name, give Triangle’s Employment Specialist and its associate’s permission to discuss my needs and capabilities with potential employers. I understand that these discussions will only occur in an effort to educate and sensitize employers in relation to my needs and capabilities in securing employment.
Signature

Clear
Date

MonthDayYear
Date
Section B:
At this time, I, First Name Last Name would prefer not to disclose information about my needs and capabilities to potential employers.
Signature

Clear
Date

MonthDayYear
Date

Criminal Offender Record Information (CORI) Acknowledgement Form
THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 MASS.GOV/CJIS

This form is not to be faxed. Please return form to organization.

To be used by organizations conducting CORI checks for employment or licensing purposes.
Organization   is registered under the provisions of M.G.L. c.6, 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, or current licensees.

As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to   Organization to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing   Organization with written notice of my intent to withdraw consent to a CORI check.

I also understand that   Organization may conduct subsequent CORI checks within one year of the date this Form was signed by me.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
Signature of CORI Subject

Clear
Date

MonthDayYear
Date
SUBJECT INFORMATION
Please complete this section using the information of the person whose CORI you are requesting.

The fields marked with an asterisk (*) are required fields.
First Name
Middle Initial
Last Name
Suffix (Jr., Sr., etc.)
Former Last Name 1
Former Last Name 2
Former Last Name 3
Former Last Name 4
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Place of Birth
Last SIX digits of Social Security Number
Type "none" and check box below if you do not have a social security number.
No Social Security Number
Sex
Height
Eye Color
Race
Driver’s License or ID Number
State of Issue
Father’s Full Name
Mother’s Full Name
CURRENT ADDRESS
Street Address
Apt. # or Suite
City
State
Zip Code
SUBJECT VERIFICATION
Please upload a photo or scan of your ID or driver's license.

Cancelof
The above information was verified by reviewing the following form(s) of government‐issued identification:
Print Name of Verifying Employee
Signature of Verifying Employee

Clear
Date

MonthDayYear
Date

Informed Consent Media Release
This form will allow Triangle to promote its programming by highlighting your success.
SECTION I. Personal Information:
Individual's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SECTION II. Permission to Use Images:
- Check the first box to give Triangle, Inc. permission to use one or more photos of you.
- Then, check Box A. if you wish to give Triangle, Inc. ongoing permission to use any images of you.
- Or check Box B. if you only wish to give Triangle, Inc. permission to use one or more specific images of you.
- You may check both A. and B. if you wish to give Triangle, Inc. permission to use both specific images of you and ongoing permission to use any images of you.
Permission to Use Images:

I am providing my permission for the ongoing use or disclosure of photographs, and images taken of me (or the individual for whom I am guardian) and that Triangle, Inc. does not have to obtain my permission for additional uses of my image(s) and/or information that I have authorized above during the term of this Permission for Release.
Options to Use Images:

A. I hereby provide my permission to Triangle, Inc. to use any photographic image(s) and/or video(s) of me for the following purposes: on Triangle. Inc.’s digital and printed marketing material to promote Triangle, Inc.B. I hereby provide my permission to Triangle, Inc. to use specific photographic image(s) and/or video(s) of me (email attached image) for the purposes listed below.
Images may be used for the following purposes:
- Posting to the Triangle, Inc. Website and/or Social Media Accounts (e.g. Facebook, Twitter, Instagram, etc.).
  - Note: social media posts may include personal information identifying me by name. By checking this box, you acknowledge that image(s) and/or video(s) posted on the internet can be viewed and downloaded by others and that social media posts may be shared or re-tweeted by other accounts once posted by the Triangle, Inc. and you hereby consent to the same.
- Informational Brochures or Pamphlets
- Photographic or Video Presentations for Public Display
- Photographic or Video Presentations with Personal Information for Public Display
- Other
SECTION III: Written Consent
I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information I already permitted to be released. If I revoke my permission, I must do so in writing and present it to the Triangle, Inc., staff or office authorized to use or disclose my images or information by this Permission for Release. I understand that once the above image(s)/information is/are disclosed, recipient(s) may re-disclose it and the material may not be protected by federal or state privacy laws or regulations. I understand my consent to the use or disclosure of my image(s) or information is voluntary and I do not need to sign this form to continue to receive services from Triangle, Inc.

Questions? Contact Kassi Soulard, Development at ksoulard@triangle-inc.org
Signature of Individual or Guardian

Clear
Date

MonthDayYear
Date
Full Name

First NameLast Name
Identify legal authority if signed by Guardian or other Legally-Authorized Representative
My consent will expire Date (date or event - must not exceed one year).

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DTA Intake Meeting Checklist

Please complete the forms below by clicking the arrow next to each one. You can preview the completed form, save the form to finish later, or submit the form using the buttons at the bottom.

Emergency Fact Sheet Information

To establish a supportive and professional relationship with clients. Please note: your Employment Specialist will discuss these guidelines with you as well.

By signing this form, permission is granted by the client for Triangle to discuss agreed upon topics with agreed upon people designated by the client.

By signing this form, you are giving Triangle permission to perform First Aid and or obtain medical assistance is the case of an emergency.

This form gives Triangle permission to discuss your needs and capabilities with potential employers. Please sign either section A or section B.

SUBJECT INFORMATION

CURRENT ADDRESS

SUBJECT VERIFICATION

This form will allow Triangle to promote its programming by highlighting your success.

SECTION III: Written Consent