Supports for Success Application

  • Supports for Success Application

  • Supports for Success is a free comprehensive case management program for adults motivated to become more self-sufficient through the achievement of employment, education or training, and/or financial goals. The program provides:

    • One-on-one coaching
    • Goal planning
    • Resources and referrals
    • Ongoing encouragement
    • Financial counseling (budgeting)

    Please note that Supports for Success is not an emergency financial assistance program and does not provide direct rent or utility assistance. If you are seeking emergency financial assistance (e.g., for rent, utilities, etc.) and are not interested in ongoing services offered through the Supports for Success program, please do not proceed with the application and instead reach out to the following resources:

    • PA 2-1-1 Southwest: Dial 2-1-1 or visit www.pa211sw.org
    • Allegheny Link: 1-866-730-2368

    To be eligible for the Supports for Success program, applicants must:   

    • Live within the Mon Valley region of Allegheny County (Applicants cannot be residents of the City of Pittsburgh)
    • Be at least 18-years old
    • Have an employment, education, and/or training goal, and/or willing to identify and work towards one starting at enrollment
    • Able to provide income and benefits verification at enrollment, recertification, and as needed
    • Able to regularly engage in services, make progress toward goals, and attend once a month one-on-one Zoom and/or in person meetings
    • Have a gross household income (before taxes) at or below the limits shown in the eligibility chart
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  • Supports for Success is funded in whole or in part under the Community Services Block Grant (CSBG) from the Federal Department of Health and Human Services under the administration of the Commonwealth of Pennsylvania, Department of Community and Economic Development. Allegheny County Department of Human Services is the local agency which makes the CSBG funding award.

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  • Supports for Success Application

    The following information is required to determine eligibility for the applicant to participate in the Supports for Success Program. Please print all information clearly. Failure to complete this application correctly and fully could result in the applicant not being accepted. All information will be kept confidential.
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  • Format: (000) 000-0000.
  • Does this phone number accept text messages?*
  • Format: (000) 000-0000.
  • Marital Status*
  • Are you a veteran?*
  • Are you a migrant?*
  • Ethnicity*
  • Race (check all that apply)*
  • Medical Conditions (check all that apply)*
  • Do you have any physical or mental health conditions, limitations, disabilities, or challenges, either past or current, that affect or have affected your daily activities, work, school, or training?*
  • Have you experienced challenges with drug and/or alcohol use or addiction, either currently or in the past?*
  • What's the highest grade you achieved?*
  • Do you have any delinquent student loans?*
  • Are you currently in school, college, and/or training program?*
  • Employment status:*
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  • Supports for Success Application

    Household Income & Benefits
  • What is the household's family type?*
  • What 's the household's housing status (check all that apply)?*
  • What type(s) of medical coverage does the household receive (check all that apply)?*
  • What benefits does the household receive (check all that apply)?*
  • What sources of income does the household receive (check all that apply)?*
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  • Supports for Success

    Applicant's Goals and Needs
  • What are some things you want to work on and achieve if enrolled in Supports for Success? (Check all that apply)*
  • What are some things you think you need help with to achieve your goals? (Check all that apply)*
  • Do you have a criminal history that are barriers to employment, education, etc.?*
  • Do you utilize public transportation as your primary source of transportation?*
  • Do you have a valid driver's license (not expired, suspended, or revoked)?*
  • Do you have a reliable vehicle?*
  • Are you working with any other program/organization on your goals or needs?*
  • Format: (000) 000-0000.
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  • Should be Empty: