7/30/2019 PSM: Stubbs Assistance Request Screening Form

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DRAFT to be adapted by each Parishs situation. CC PPP 1-18-12

Date:____________Time:_____________Informationtakenby:______________NameofCaller:_____________________________________________________

ContactPhoneforcallback(somecallswillrequireadecisionfollowingconsultationwithpastororotherresearch):______________________________

Request:______________________________________________________________________________________________________________________________Meetsthefollowingcriteriaorresourcesavailable:

Liveswithinservicearea......... . [ ]yes [ ]no Resourcecurrentlyavailable...... ..[ ]yes [ ]no Parishionerorrelated..............[ ]yes [ ]no Churchhasministryaddressingneed [ ]yes [ ]no .......... [ ]yes [ ]no .......... [ ]yes [ ]no .......... [ ]yes [ ]no .......... [ ]yes [ ]no

Churchisabletoassistwithintheiravailableministries/services:[ ]yes [ ]no

Ifyes,

Services

Provided:

____________________________________________

Ifno:

ReferredtoCatholicCharitiesifapprovedbypastor[ ]yes[ ]noNameofCCstaffreceivingthereferral_______________________________________

ReferredtoOtherPrograms:____________,______________,_________ Persontoldthatservicesarenotavailable[ ]yes,[ ]no

FollowupNeeded:[ ]no. [ ]yes:____________________________________

AdditionalInformation:

Filereportandlognameandcontactinformation

__________ Church,___________,N.Y.

AssistanceRequestScreeningForm