NC Participant Reverse Referral Form

More Than A Job NC Screening and Referral Form
Thank you for your interest in The HELP Center’s More Than a Job-NC Training Program. Please complete the form below, and a member of our Case Management Department will reach out to you shortly to discuss your enrollment and next steps. We look forward to supporting you on your journey toward success.
Name*

First NameLast Name
Mailing Address (Include City, State and Zip)*
County of Residence*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Last 4 of SSN*
Are you interested in education and/or training?*

YesNo
Are you currently interested in obtaining employment?*

YesNo
Do you have any challenges to employment such as transportation, childcare, education requirements etc.?*

YesNo
Services of Interest

Job Search Training (Work Readiness)Vocational Training
Date

MonthDayYear
Date
Referral Partner Name
Referral Partner Email
example@example.com
REFERRAL RESULT (To be completed by NCDHHS or local DSS)
I understand that this is a voluntary program, and it does not affect my FNS benefits. While I understand that this is a voluntary program, I agree to fully participate in order to increase my chances of finding employment or getting a better job.
Participant Signature

Clear
Date

MonthDayYear
Date
Should be Empty: