Client Intake/Outcome Form

 

CVM START DATE:        CVM END DATE**:
 

 

Agency Name* 
Agency Security Code*     Agency Case Worker Name   
Client First Name* Middle Initial Last Name* Suffix (eg, Jr.)
Social Security # (optional)    Choose one: Full SSN    Partial SSN    Don’t know or don’t have Refused
VoiceMail Extension Assigned to this Client*  Password (if applicable) 
 

CVM Client Agreement of Understanding

I understand that I have the temporary use of a Community Voice Mail phone number to use ONLY for the purposes and length of time agreed upon by me and the service provider who is giving me this number.  I agree to contact the service provider to let him/her know my outcome, whether the voicemail service was helpful, and/or whether I no longer need the voicemail box.  I understand that the information in this form will be kept confidential and used only to keep track of CVM services and/or to check CVM eligibility by service providers or funders who have agreed to confidentiality.  I understand that the service provider will receive a regular printout on the usage of this voice mail box.  This will assist CVM in evaluating the overall effectiveness of the program.

* this field is required.

CLIENT INFORMATION

Age Range (mark one):
under 18
18-25
26-44
45-59
60 and up

unknown

Date of Birth

Ethnicity (mark one):
Non-Hispanic/Non Latino
Hispanic/Latino
Unknown

Race (mark ALL that apply):
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Unknown
 

Gender:      Male      Female

Current Monthly Income $

Income Sources (mark ALL that apply):
  Earned Income
  Unemployment Insurance
  SSI
  SSDI
  Other Disability Income
  TANF (or local equivalent)
  OWF
  Pension/Retirement Income
  Child Support
  Other Source
  No financial resources

 

Other Characteristics/Situations:
(mark ALL that apply)
Homeless
At Risk of Homelessness
Unemployed
Limited English Skills
Victim of Domestic Violence
Foster Care participant (current or recent)
Parolee/Prisoner Re-entry Program
In-housing – phone disconnected

Veteran Status?   Yes   No
Disabling Condition?   Yes   No

Head of Household?   Yes    No


# of Dependent Children  
# of Dependent Adults  


If Homeless (mark one):
Living in Emergency Shelter
Living on Streets
Living in Transitional Housing
Doubled up with Family/Friends
 

 

CLIENT GOALS & OUTCOMES FOR CVM (circle all that apply)
 

** leave blank unless you are taking the client off of the system

 

Goal: Employment

Yes   No

Outcome: Employment**

Yes   No   Unknown

Goal: Housing

Yes   No

Outcome: Housing**

Yes   No   Unknown

Goal: Health Care

Yes   No

Outcome: Health Care**

Yes   No   Unknown

Goal: Social Services

Yes   No

Outcome: Social Services**

Yes   No   Unknown

Goal: Safe Communications

Yes   No

Outcome: Safe Communications**

Yes   No   Unknown

Goal: Other Reason(s)

Yes   No

Outcome: Other Reason(s)**

Yes   No   Unknown

Please describe "other reason(s)":  

 


Exit Reason - What was the primary reason for ending usage/exit? (mark one)**
Client accomplished goals   Client abandoned voicemail box   Client left agency program or service area
Client reached maximum time limit   Other reason:  
 

 

Exit Question: “How helpful was CVM in achieving the outcome(s)?” **
 

Very helpful

Somewhat helpful

Not very helpful

Not at all helpful

No information/data available

 


* this field is required.
** leave blank unless you are taking the client off of the system
 

When you click the submit button, a confirmation page will appear with the information that you have entered. 

From there, you can use the back button on your browser to return to the Community Voice Mail page.