Bike Voucher Assessment
Release of Information
CM Client Terms and Agreement
SALT Bicycle Liability Agreement
Client Signature for Documents:
Was a release of information form completed?
*
Yes
No
If no, why not?
General Information
Full Name
First Name
Last Name
Alias (if applicable)
Gender Identity
Male/Man
Female/Woman
TransMale/TransMan
TransFemale/TransWoman
Genderqueer/Gender nonconforming
Decline to Answer
Other
Race
American Indian
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Client does not know
Client refused to answer
Data not collected
Other
Ethnicity
Hispanic/Latino
Non-Hispanic/Non-Latino
Client does not know
Client refused to answer
Data not collected
Other
What is your birthday?
*
-
Month
-
Day
Year
Date
How old are you?
YYA Grant Eligibility
Clientele ages 16 to 24 can receive case management via appointment with YYA worker to do an assessment to see if they qualify for youth-specific services. The outreach worker may be able to come on site for the appointment. Contact: Mayra@saltoutreach.org / Alexandra@saltoutreach.org / Renae@saltoutreach.org
*** Populates if below the age of 25 *** Are you interested in any of the following?
Transitional Housing?
Dedicated Case Management?
Help with Transportation
GED or College Degree
Looking for help with resume building and cover letters
Learning customer service skills
Help with applying for jobs online or in person
Professional attire
Conflict resolution training
Personality assessment or career assessment tools
Communication or teamwork training
Looking for internships or mentors
Financial literacy training
Parenting classes
If any of the above were checked you can make this referral. Was this referral made?
Yes
No
Why was the referral not made?
Do you have a phone?
*
Yes
No
Phone Number
Email Address
example@example.com
Do you have regular internet access?
Yes
No
How often do you have internet access?
Daily
Every few days
Weekly
Bi-Weekly
Do you have an address?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you need help with rent or utilities at your home or apartment?
Yes
No
Christian Service Center - Utility/Rent Help Eligibility
Phone Number: 407-234-1922
Is the home or apartment you are seeking rent or utility assistance with in your name? If no, they will not qualify for help from the Christian Service Center.
Yes
No
What county is your apartment/house?
Orange
Seminole
Osceola
Other
The Christian Service Center only serves people in Orange County. You will need to refer client to other resources if not in Orange County.
Yes
No
Why are you unable to pay for your rent/utilities? If none of these they do not qualify.
Death in the family?
Emergency Situation? Explain below.
Lost your job?
Employed but experienced loss of wages due to hospitalization?
Employed but have not received first check yet?
None of the above
What is the emergency situation?
If they cover their rent or utility bill for this month will they be able to pay their rent or utility bill the following month without assistance?
Yes
No
Have you already been served an eviction notice?
Yes
No
If they are unable to pay rent for one of the eligible reasons listed above, if they are unable to pay for their own rent and utility bill the following month without assistance if the current month is covered, or if they were served an eviction notice they will not be eligible. You can mention they won't be eligible for Christian Service Center assistance but refer to your supervisor to see if there may be other options.
Make referral to the Christian Service Center, was referral made?
Yes
No
If not, why was referral not made?
Do you need help with groceries or food for a few days?
Yes
No
Christian Service Center - Food Pantry
Walk over to the food pantry. There are snack items for those experiencing homelessness and there are items that you can cook and prepare for people who have homes, apartments, or are in a motel. You will need to use the IPAD in the Food Pantry to check out items.
Was this referral completed?
Yes
No
If not, please explain why.
Where did you sleep last night?
*** (Do not ask this question, mark "Yes" if they said anything other than "a house" or "apartment" in the previous question) *** Are they experiencing homelessness?
Yes
No
What was your living situation prior to becoming homeless?
How long was your prior living situation?
Approximately how many years have you been experiencing homelessness?
Provide a brief summary of what led you to experiencing homelessness?
Do you have all of your Identification Documents?
Yes
No
Do you need any of the following?
ID
SS Card
Birth Certificate
Are you an American Citizen? If any of the above documents is needed and client confirms they are a citizen, refer to Vote Riders. If client is a non-citizen, Complete Online Form for Idignity: https://www.tfaforms.com/4816854; and refer client to go to Idignity in person Tue & Thurs 8:30am- 2:00pm. Phone 407-792-1374; Email info@idignity.org; Address: 425 N Magnolia Ave, Orlando 32801
Yes
No
Are you a Veteran?
Yes
No
VA Benefit / Shelter Eligibility
Were you ever activated? If they were not activated they would not be eligible for VA benefits/shelter.
Yes
No
Were they dishonorably discharged? If they were dishonorably discharged they will not qualify for benefits/shelter through the VA.
Yes
No
Do they have a DD 214 or Veteran ID? (not required but preferred)
Yes
No
** Refer to the VA by emailing Kristopher Vite at Kristopher.Vite@va.gov or calling his cell at 407-414-0633 ** Was a referral made?
Yes
No
Why was referral not made?
Employment History & Income
Are you currently employed?
Yes
No
Where are you employed?
Do you have proof of employment?
*
Yes
No
If a client does not actively have proof of employment, they will not be eligible for this assessment and thus cannot receive a bike. Please have them return for an full initial assessment if they are SEARCHING for employment. Feel free to type any details here.
How much is your current income?
Did you provide the client with a bike voucher slip for Rusty (if they are eligible)?
Yes
No
Notes and Follow-up
Enter any notes on the client and the interaction in this field.
Notes
Follow-up Appointment
Initial Assessment Completed with:
Please Select
Renae
Kathy
Yael
Glory
Kyra
Alexandra
Mayra
Gina
Dawn
Kimary
Follow-up Appointment with:
Please Select
Renae
Kathy
Yael
Glory
Kyra
Alexandra
Mayra
Gina
Dawn
Kimary
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