M:STL General Referrals & Resources_v2
Date of Referral or Handout
CLIENT DETAILS
Client's Full Name
Client's Birthdate
Program Engagement
Program
Program Engagement ID
is the person in Salesforce?
Yes
No
NEW CLIENT CONTACT INFO & DEMOGRAPHICS
Client's First Name
Client's Last Name
Client's Birthdate
Client Phone Number
Phone Number Type
Please select...
Mobile
Work
Home
Other
Can we text you at this phone number?
Yes
No
Client Email Address
Zip Code
How many LIVE at your house INCLUDING yourself?
Please select...
1 (only you)
2 (you + 1 other person)
3 (you + 2 other people)
4 (you + 3 other people)
5 (you + 4 other people)
6 (you + 5 other people)
7 (you + 6 other people)
8+ (you + 7or more other people)
Race
African American/Black
American Indian
Asian
Hawaiian or Other Pacific Islander
Caucasian/White
Biracial
Multiracial
I do not wish to answer
Other
Other race
What would you like to record for this client?
(check all that apply)
An external referral
An internal referral (to another program at M:STL)
A resource handout
A case note
A check-in service delivery
An application for rent/utility assistance
EXTERNAL REFERRAL INFORMATION
Type of referral
I scheduled an appointment for them
I provided a warm hand-off to the referral partner
I provided them with referral information only
Other
What type of referral are you providing?
Career Resource
Financial Resource
Housing Resource
Legal Resource
Life Skills Resource
Medical/Healthcare Resource
Mental Health Resource
Parenting/Family Support
Social Support Resource
Transportation Resource
Organization
Organization ID
Reason for referral:
If you cannot find the organization, please -----.
INTERNAL REFERRAL INFORMATION
Which internal program are you referring the client to?
Please select...
Beyond Jobs
Beyond Justice
Minor Home Repair
NHN
Resource Team
SHOW ME PEACE
Priority of program contacting participant:
High
Medium
Low
Reason for referral:
Aqe qualification:
Senior Citizen (60+)
Legally Disabled
Neither
Is lower-moderate income?:
Yes
No
Owns their home?:
Yes
No
Lives in St. Louis City?:
Yes
No
Is up-to-date on property taxes?:
Yes
No
Are you within the age range of 18-50?
Yes
No
Do you currently have consistent & stable housing?:
Yes
No
If you have children who require care during the day, do you have reliable daytime childcare during program hours?:
Yes
No
Not applicable
Are you available 9 hours per week?
Yes
No
Do you currently receive any benefits or supplemental income that may affect your work availability or the number of hours you are able to work?
Yes
No
Are you available on
Tuesday through Thursday
during any part of the
timeframe
of
10:00 AM–3:30 PM?
(Days & Times sub
ject to change)
Yes
No
7.
If approved for Beyond Jobs, which
class start dates
work best for your schedule?
Please select no more than 2.
May 5
June 2
July 7
August 4
September 1
October 6
November 3
*This person is NOT eligible for the Minor Home Repair Program. PLEASE LET THEM KNOW. Based on their needs please refer them accordingly. They will NOT be contacted by a M:STL staff member.
RESOURCE HANDOUTS
Resource Provided
Service SF ID
HANDOUT DETAILS
Please fill out the details about the resource provided below.
Number of pairs of shoes
ASSISTANCE LEAGUE
Description of Request
In kind dollar amount ($)
FOOD PANTRY
Enter the quantity of each type of item below:
Canned MEAT
Desserts
Seasonings, Jams & Condiments
Canned SOUP/PASTA
Canned/Dried FRUIT
Beans, Rice and Potatoes
Canned VEGETABLES
Cooking Products
Baking
Drinks
Pasta
Cereal/Breakfast
Baby Products
Dairy
Meat
TOTAL Number of Items
DIAPERS
Enter the below information for 1 child. For each additional child, click the "Add another response" button in the bottom right.
Child's Name
Child's Race
African American/Black
American Indian
Asian
Hawaiian or Other Pacific Islander
Caucasian/White
Biracial
Multiracial
I do not wish to answer
Other
Diaper size
Number of packs
PERIOD PACKS
Number of packs
CLOTHES CLOSET
Type
Men's
Women's
Enter the quantity of each type of item below:
Accessories
Belt
Blouse
Jacket
Dress
Pants
Shirt
Skirt
Shoes
Suit
Tie
Vest
TOTAL Number of items
HOUSEHOLD GOODS
Enter the quantity of each type of item below:
Air Freshener
Awesome/Bleach
Bathroom Tissue
Broom
Bucket
Dish Detergent/Pods
Foil
Household Cleaner
Laundry Detergent
Paper Towel
Sponges
Toilet Bowl Cleaner
Trash Bags
Window Cleaner
TOTAL Number of items
PERSONAL CARE ITEMS
Enter the quantity of each type of item below:
Adult Diapers
Body Powder
Bodywash
Deodorant
Hand Soap
Lotion
Mouthwash
Peroxide/Alcohol
Razor
Shampoo
Shave Cream
Toothbrush
Toothpaste
Vaseline
TOTAL Number of Items
SEASONAL ITEMS
Enter the quantity of each type of item below:
Building/Work Supplies & Tools
Cold Weather/Warmth
General Supplies
Power & Connectivity
Safety & PPE
Weather Protection & Waterproofing
Winter Car/Outdoor Readiness
TOTAL Number of Items
CLIENT NOTE
Subject
Type of Interaction
Please select...
In-Person Meeting
Phone Call
Text Message
Case Note
CHECK-IN SERVICE DELIVERY
Only log this if you spent time doing a check-in, in addition to making a referral or providing a resource (i.e. making/updating goals, discussing progress and next steps, discussing issues/concerns, etc.)
How long was the check-in?
Please select...
15 minutes
30 minutes
45 minutes
1 hour
1.5 hours
2 hours
Additional notes?
APPLICATION FOR RENT/UTILITY ASSISTANCE
Number of applications
Type of application:
Amount applied for:
Additional details?
Staff Member Email
Contact Information