Intake Packet For Employment Services
Pittsburgh Community Services, Inc. (PCSI) was established in 1983 as the designated Community Action Agency (CAA) for the city of Pittsburgh and has served as the anti-poverty agency for the city for over 30 years. PCSI serves approximately 6,000 individuals annually. Below you will find our electronic enrollment for services with Pittsburgh Community Services. All items with a red star must be completed.
Is this your first time working with Pittsburgh Community Services, Inc.?
Who was your referral source?
PCSI Staff Member
Social Media-Facebook, TikTok, etc.
Which office is more convenient for you?
Oakland-249 N. Craig St.
Southside-50 S. 7th St.
Please complete all fields
Is this a cell phone?
Ok to receive text messages about upcoming events at PCSI?
Street Address Line 2
State / Province
Postal / Zip Code
What Neighborhood do you live in?
Do you have a valid Driver's License?
Check all Services that you are interested in receiving from PCSI Workforce Development Department:
Resume/Cover Letter Help
Mock Interview Skills/Virtual Interviewing
Job Readiness Workshops
Job Leads & HR Referrals
Earning a GED
Obtaining a Driver's License
Do you have a Criminal Background?
If yes, charges?
What area of employment are you interested in? (Check all that apply):
Are you a veteran?
Dates of Service:
Are you currently employed?
Work Experience 1:
Work Experience 2:
Please complete the following questions to help PCSI assess your needs.
Family Dynamics & Housing
Live with Partner
In the box below, list all members of the household. Please include their age, relationship and education level:
Grade Levels of Children Living in the home
Describe your housing situation:
Other Permanent Housing
Health and Well Being
Select the best option to describe your health insurance situation:
Select the best option to describe your children's health insurance situation:
Your Highest Level of Education:
High School Diploma
List any special learning needs:
List any special training or skills:
Describe your employment situation:
Employed Full Time
Employed Part Time
What are your long term employment goals?
What is your transportation situation?
Own a vehicle
Has daily access to a vehicle
Public transportation (Bus)
Do you receive any form of Income? (check all that apply)
No income at this time.
Public Assistance, Social Security or SSI
Child Support, Alimony or regular monetary gift from family friends
Assets: Stocks, Inherited property
Interest income from savings, checking, Christmas club, money market etc.
U.S.Saving Bonds, Stocks or Bonds
Pension, annuities, retirement funds, etc.
Real Estate Property, earned income tax credit, etc.
Other income, property sold, babysitting, tips, etc.
Non Income Affidavit: I do hereby swear and affirm that I do not have any source of income. This includes but is not limited to income from any of the following: 1.Wages, Public Assistance (ADC, GR etc.) Social Security, SSI etc.: 2. Child Support, Alimony or regular monetary gifts from family, friends, etcs: 3. Assets (Homes, stocks etc. may be inherited property); 4. Interest income from savings, checking, Christmas club and other bank accounts, IRA’s, Certificates of Deposit, Money Market Funds, Credit Unions, etc.; 5. U.S. Savings Bonds, Stocks or Bonds of any kind; 6. Pensions, annuities, retirement funds, etc. (this includes benefits you may receive from being beneficiary of a lift insurance or retirement plan;) 7. Real Estate Property, Earned Income Tax Credit, etc.; 8. ANY OTHER INCOME (includes tips, property sold, babysitting etc. “
Do you receive any of the following? (check all that apply)
Housing Choice Voucher
Permanent Supportive Housing
Child Care Voucher
Affordable Care Act Subsidy
PCSI offers other services to clients in need. Do you need any of the following services?
Supportive Services(Photo ID, Furniture, etc.)
Support groups(Parenting, Counseling, etc)
Referral to resources
Please upload available documents listed below.
Check all documents that can be provided:
Social Security Card
Driver's License/Photo ID
Proof of Residency
Social Security Determination Letter
Department of Human Services Benefits Letter
Unemployment Benefits Letter
Proof of Citizenship: Load 1 picture of 2 forms of ID. This can include Pennsylvania Driver License, Social Security Card, Pass Port, Birth Certificate, Pennsylvania State Photo Id.
Drag and drop files here
Choose a file
If you have income verification please upload the document here. (Pay Stub, Social Security Benefits, State Assistance, Unemployment Compensation, Pension...)
Drag and drop files here
Choose a file
Please upload Resume here.
Drag and drop files here
Choose a file
Participation Agreement: Pittsburgh Community Services, Inc. is offering Development Series Workshops to all eligible PCSI customers if you have received one of the following services: Food Assistance, Utility Assistance, Work Ready Program, Workforce Development & Training, and/or housing listing distribution. To remain eligible for PCSI services you must remain in good standing with regular attendance to participate in workshops and other various programs directed by PCSI. You will be strongly encouraged to attend 2 workshops. The workshops will be held bi-monthly at 249 N. Craig Street,Pittsburgh, PA 15213. Your signature denotes agreement to be contacted by PCSI staff members with dates and class schedules. Participant/PCSI Acknowledgement
Photo Release Form
PHOTOGRAPHIC& VIDEO RELEASE FORM The undersigned hereby gives permission to Pittsburgh Community Services Incorporated (PCSI) to capture and use a photographic and or video like of myself for purposes related to program advertisement, news copy, web site photos, agency reporting, and recruiting of participants eligible for the services offered by PCSI, or authorized by PCSI for similar purposes within their domain and under their complete control. My image(s) may not be used for commercial gain without my specific written consent. My image(s) and or likeness may be used in and on program brochures and or advertisements designed to attract capital investment in PCSI programs and projects, or to win funding from contributors,donors and or foundations grantors. My permission may be revoked at any time by giving written notice to the undersigned PCSI staffer or the agency’s Chief Program Director. Signature:
PCSI Grievance Procedure: 1. PCSI wants everyone receiving their programs and/or services to be satisfied. If for some reason a customer is not satisfied with a program and/or service received from PCSI; they will be requested to document their complaint in writing. They will need to identify their initial interest in the program and/or service and detail their related concern with the staff associated with that program. If their complaint cannot be resolved with the program staff, they may request a meeting with the Chief Program Director. 2. The Chief Program Director will meet with the customer and program staff to discuss the complaint. The Chief Program Director will review all necessary information and make every attempt to resolve the situation. If the customer was referred by another source, that source will be contacted if necessary. If the issue is resolved, the customer must sign documentation that states that they agree to the continuation of services. If the issue is not resolved, the customer may request to meet with the Executive Director. 3. If it is decided that PCSI is not the appropriate agency for services, the customer will be referred to external resources.
Submit for Eligibility
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