Triangle, Inc. Intake Form

Intake Meeting Checklist
Intake Paperwork
1. Workforce Development Guidelines: to establish a supportive and professional relationship with clients. *Mandatory
2. 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.
3. Guardianship Verification: this form is only applicable if the client is under 18 or under guardianship from the court.
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:*
Typed signature of Employment Specialist
Date*

MonthDayYear
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.
- To establish a supportive and professional relationship with clients. Please note: your Employment Specialist will discuss these guidelines with you as well.
  
  *Mandatory
- Below are guidelines of Triangle Inc.’s Workforce Development Department. These guidelines are established to promote and maintain a supportive and professional relationship between a client and Triangle staff. All clients are required to follow these guidelines to receive services through Triangle.
  1. General
    
    Triangle celebrates the diversity and individuality of its clientele and staff members. While at a Triangle office, all who enter will be treated fairly and with respect.
    
    The personal space and boundaries of all persons will be respected.
    
    All persons will follow office procedures and safety protocols
  2. Communication (between Triangle staff and clients)
    
    In person
    
    Conversations will remain professional and respectful
    
    Conversations will be focused on employment and vocational goals
    
    Appropriate and respectful language will be used at all times
    
    Communication should take place during business hours: 8:00am – 5:00pm, Monday – Friday (Unless circumstance dictates otherwise, such as client is scheduled for an interview, there is an emergency on the job, etc.)
    
    Via technology (Email, Phone, Text) Please include your name in your communications.
    
    Communication via technology will always be employment focused and remain respectful
    
    Texting will be used for communicating only if agreed upon by the client and Employment Specialist and the following guidelines used:
    
    If texting, do not send multiple text messages. Please wait for a response from the Employment Specialist.
    
    Emails will be responded to as possible by Employment Specialist
    
    Clients are encouraged to call or email their Employment Specialist with questions, ideas, suggestions, for advice, etc. But should understand one call or email will suffice and their message will either be responded to before, or during the next meeting, depending on the situation.
    
    When calling your Employment Specialist please leave a detailed, professional message and wait for a response. Employment Specialists will respond appropriately.
  3. Meetings
    
    Time will be used wisely and remain on task.
    
    Both parties will show up prepared and ready to work.
    
    If canceling a meeting, do so within an appropriate time frame while following communication guidelines.
- Not adhering to guidelines will result in a meeting with Employment Specialist, the client, and VR counselor, and may result in termination of services.
- Typed signature
- Date*
  
  MonthDayYear
- 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.
- Typed signature of individual authorizing release
- Date
  
  MonthDayYear
- This form is only applicable if the client is under 18 or under guardianship from the court.
- I, First Name Last Name am my own guardian and I am responsible for managing my own medical, legal and financial decisions.
- First Name Last Name has been deemed incompetent by probate court to manage decisions in the following matters:
  Medical Legal Financial
- I/We, First Name Last Name have been appointed guardian of First Name Last Name.
- A copy of the Guardianship Decree (not the Petition for Guardianship) must be attached to this form for the individual's file. Please upload it here.
  
  Cancelof
- Typed signature fo self/guardian
- Date
  
  MonthDayYear
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Home Phone Number
  Please enter a valid phone number.
- Work/Cell Phone Number
  Please enter a valid phone number.
- 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.
- Typed individual's signature
- Date*
  
  MonthDayYear
- Typed guardian's signature (if necessary)
- Date
  
  MonthDayYear
- 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.
- Typed signature
- Date
  
  MonthDayYear
- Section B:
  At this time, I, First Name Last Name would prefer not to disclose information about my needs and capabilities to potential employers.
- Typed signature
- Date
  
  MonthDayYear
- 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.
- Typed signature of CORI Subject
- Date
  
  MonthDayYear
- 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
- 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
- Typed signature of Verifying Employee
- Date
  
  MonthDayYear
- This form will allow Triangle to promote its programming by highlighting your success.
- SECTION I. Personal Information:
- Individual's Name
  
  First NameLast Name
- 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
- Typed signature of Individual or Guardian
- Date
  
  MonthDayYear
- 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).
- Should be Empty:

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.

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.

This form is only applicable if the client is under 18 or under guardianship from the court.

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