STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

WELFARE-TO-WORK PLAN PARTICIPANT NAME

RIGHTS AND RESPONSIBILITIES
This is an overview of the rights and responsibilities of participants in
Welfare-to-Work activities under the California Work Opportunity and
Responsibility to Kids (CalWORKs) Program. Your Welfare-to-Work
Plan tells how you and the county will work together so that you can
get and keep a job. Your plan includes this form, the Activity
Assignment, and the Welfare-to-Work Handbook. The Welfare-to-
Work Handbook tells you about Welfare-to-Work activities, services,
and rules. The Activity Assignment tells you the Welfare-to-Work
activity that you will be participating in.
The county must do certain things to help you while you are in
Welfare-to-Work. The county must explain Welfare- to-Work to you
and answer any questions.
ALEJANDRINA CORDOVA
CASE NAME
ALEJANDRINA CORDOVA
CASE NUMBER WORKER ID
1B8V096 37LS2P9N01
The county must help you arrange and pay for child care,
transportation, and work and training costs. If necessary, the county
can make advance payments to you for these supportive services.
This plan and any changes to it will apply to you and the county as
long as you participate in Welfare-to-Work. But, the county may
have to change or stop all or part of this plan if: 1) there are changes
in law or regulations; 2) the county cannot get or pay for services
from the provider; or 3) you stop receiving cash aid under the
CalWORKs program. The county will inform you of any changes in
writing.

YOUR RIGHTS
As a Welfare-to-Work participant, you have the following rights which will help you take part in Welfare-to-Work.
You have the right to the following:
Employment Services
• Receive direction and support from the county to help you improve your ability to get a job. This can possibly include on-the-job training
and job skills training or education.
• Receive a referral to places that offer personal counseling, mental health, substance abuse, or domestic abuse services, at no cost to
you, if you need them to help you participate.

Supportive Services
• Receive payment for child care, transportation, and work and training-related expenses if you need them to participate in or attend any
Welfare-to-Work appointment or activity. These are called supportive services. If you need them, but do not get them, you may have
good cause for not participating.
• Receive details of your supportive service arrangements in writing.
• Receive advance payment, if you need it to avoid using your own money, for approved supportive services.

Welfare-to-Work Plan
• Ask for a change or reassignment to another activity within 30 days from the beginning of your first training or education assignment
under your initial Welfare-to-Work plan.
• Change your mind about the activities assigned in your Welfare-to-Work plan. If you change your mind, you must tell your Welfare-to-
Work worker within three (3) working days after signing your Welfare-to-Work plan Activity Assignment form (WTW 2).
• Automatically get a neutral third party to assess your employment and or training needs if you disagree with the assessment or you and
the county cannot agree on a plan to meet your assessed employment needs.
• Ask for a different provider if you object to the religious character of any provider to which you have been assigned.
• Not to participate in any religious activity offered by a service provider. Participation in such an activity is voluntary.

Resolve Problems with your Welfare-to-Work Plan

• Not participate if the services you and the county agree you need are not provided.
• Not participate if the county decides you have any other good reason.
• Explain the reason if you fail to do what Welfare-to-Work requires.
• Have a second chance to cooperate and participate in Welfare-to-Work through the compliance process.
• Ask for legal advice at anytime regarding your participation in Welfare-to-Work from your local legal aid or welfare rights office by calling
( 877 ) 534-2524 .
PHONE NUMBER

Employment Problems
• Leave a job or not accept a job if the county decides you have a good reason.
Complaints
• Protest any county action you do not agree with by filing a formal grievance with the county or asking for a State hearing by calling
1-800-952-5253, or for the hearing or speech impaired who use TDD, call 1-800-952-8349.

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 YOUR RESPONSIBILITIES

As a Welfare-to-Work participant, you also have the following responsibilities to make sure Welfare-to-Work works for you.
You must:
• Accept a job if you get an offer, unless you have a good reason not to.
• If working, keep the job and not lower your earnings.
• Sign activity assignments which tell how you and the county will work together while you participate.
• Participate as described in your Welfare-to-Work plan unless you have a good reason.
• Choose and arrange for supportive services. The county will help you.
• Sign up for subsidized child care if you will need it. The county will tell you how.
• Ask your Welfare-to-Work worker if you have any questions about Welfare-to-Work.
• Tell your Welfare-to-Work worker of changes that may affect your participation.
• Tell your Welfare-to-Work worker right away of changes in your need for supportive services. This includes
changes in child care providers. If you do not tell the county in advance, the county may not be able to pay for
the services that change.
• Pay Welfare-to-Work back for any supportive services payments you got, but you did not need or you were not
eligible to get.
• Call or go to the county when they ask you to.
• Give proof of satisfactory progress in your assigned activity, if required by your county.
• Read (or have read or explained to you) the Welfare-to-Work Handbook and ask questions about any part of
the handbook you do not understand.
QUESTIONS?

The Welfare-to-Work Handbook gives you more information on your rights and responsibilities. If you have any questions,
be sure to check the Welfare-to-Work Handbook or call your Welfare-to-Work worker at the number shown below.

CERTIFICATION

I understand that the purpose of Welfare-to-Work is to help me prepare for work and find a job.
I have read (or had read or explained to me) and understand this Rights and Responsibilities form. I have received a
Welfare-to-Work Handbook. I know that I have certain rights and responsibilities as a participant in Welfare-to-Work. I
know that I must meet all my responsibilities as a Welfare-to-Work participant. If I fail to meet my responsibilities without
good reason, I know that there are certain penalties and that my cash aid may be affected.

PARTICIPANT’S SIGNATURE: DATE:

7/5/2023
WELFARE-TO-WORK WORKER’S SIGNATURE: PHONE: DATE:

( 619 )878-8109 7/5/2023

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

WELFARE-TO-WORK PLAN ACTIVITY ASSIGNMENT

Participant Name:
ALEJANDRINA CORDOVA Initial Activity Assignment Amendment #

Case Name: I.D. Number:

ALEJANDRINA CORDOVA 37LS2P9N01

Case Number: Wefare-To-Work Worker’s Name:

1B8V096 Rita Archuleta

✔ Mandatory participant: I agree to do the checked activity or activities listed below. I understand that if I do not participate as required
in these activities, my cash aid will be lowered, unless the county decides I had a good reason to not do them. I understand that if I am
in a two-parent family, we can share the 35-hour participation requirement, and only my assigned hours are listed below.

Volunteer: I understand that I do not have to participate, but I agree to do the checked activity or activities listed below. I understand
that as a volunteer, my cash aid cannot be lowered for failing to do these activities. I understand if I stop doing these activities, I may
have to wait to participate in Welfare-to-Work, unless the county decides that I had a good reason not to do them. I understand that the
20-,30- or 35-hour per week rules do not apply to me.

Self-Initiated Program (SIP): My primary activity is an education or training program I was enrolled in before my appraisal. If I am a
mandatory participant, the number of hours I am required to participate in each week is: 20 30.

CalWORKs Hourly Participation Requirements:

CalWORKs Welfare-to-Work Activities
Unsubsidized employment for hours Supported work and transitional
employment for hours
Self-employment for hours
Job skills training directly related to
Subsidized private or public for hours to employment for hours
sector employment
Satisfactory attendance in a
Grant-based on-the-job training for hours secondary school or in a course
leading to certificate of general
Work study for hours educational development for hours
Work experience for hours
Education directly related to for
employment hours
Community service for hours

✔ Vocational education for64 hours Adult basic education for hours

On-the-job training for hours Participation required by school to ensure

child’s attendance for hours
Job search and job readiness for hours

Mental health services for hours Other family stabilization activities for hours

Substance abuse services for hours Other activities necessary to assist in

obtaining employment for hours
Domestic abuse services for hours

Total Hourly Requirements

Each week I must complete:

Full-time education ✔ At least 30 hours.

At least 20 hours. At least hours of my family’s 35-hour requirement.

(Initial and date)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

ASSIGNMENT AND SERVICES

ACTIVITY, LOCATION, SCHEDULE, AND HOURS
ACTIVITY:
Voc/Ed Training (Educacional Vocacional)
BEGINS: EXPECTED TO END: SCHEDULE:
1.
07/05/2023 08/03/2023 (MO TU WE TH 08:00 AM - 08:00 PM flex) Lunes-Jueves 8:00a-8:00p flexilble
HOURS PER WEEK: LOCATION:
64 Southwestern College, 900 Otay Lakes Rd. Chula Vista,CA
ACTIVITY:

BEGINS: EXPECTED TO END: SCHEDULE:

2.

HOURS PER WEEK: LOCATION:

ACTIVITY:

BEGINS: EXPECTED TO END: SCHEDULE:

3.
HOURS PER WEEK: LOCATION:

ACTIVITY:

BEGINS: EXPECTED TO END: SCHEDULE:

4.

HOURS PER WEEK: LOCATION:

The county will send me the location and schedule for my activity by .
Activity Date
I will go to on/by to get my location
Location Date Activity
and/or schedule.
I will give my Welfare-to-Work worker a copy of my
Activity
schedule by . I will tell my Welfare-to-Work worker if any changes are made and give my Welfare-to-
Date
Work worker a copy of the changes if required.
I understand that if I do not go to and/or make satisfactory progress in Voc/Ed Training (Educacional Vocacional) /
Activity
, as required, I may have to go to different activities. I understand that I must give
Activity
proof of satisfactory progress in these activities to my Welfare-to-Work worker by the date(s) listed below.

Activity: Voc/Ed Training (Educacional Vocacional) Date Proof is Due: 5to de cada mes
Activity: Date Proof is Due:
Activity: Date Proof is Due:
Activity: Date Proof is Due:

✔ Additional Comments:
Las horas de mas de 30 horas por semana son voluntarias. Las horas indicadas en la pagina 1 del plan son un promedio
de horas por semana para cumplir con los requisitos semanales. Debera manterne un progreso satisfactorio en su activida
de Educacion Vocacional asistiendo y manteniendo un promedio de 2.0 o superior. Favor de notificar de cambios.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

SUPPORTIVE SERVICES
The county must give me supportive services (child care; transportation; and work, education and training related expenses)
if I need them to participate in my mandatory or voluntary Welfare-to-Work assignments and Welfare-to-Work rules allow for
them.
✔ My county worker has reviewed my need for Welfare-to-Work supportive services for each activity listed in my plan. I
understand that I do not have to do my assignment until the supportive services I need have been arranged.

✔ I understand that I must tell my Welfare-to-Work worker right away if my need for Welfare-to-Work supportive services
changes, or if I no longer need them. If I do not report the changes in advance, the county may not be able to
pay for them. I understand that if I stop participating in my Welfare-to-Workactivities, I will continue to receive child
care for the remainder of my child care authorization period or until my child care authorization is discontinued.

✔ I understand that if the county pays for supportive services that are more than what I needed to participate
in Welfare-to-Work, with the exception of child care and advance student payments, I will have to pay the county back.

I need the following supportive services:

✔ Child Care
Full-time (30-52.5 hours per week) Part-time (less than 30 hours per week)
✔ I do not need the county to pay for child care at this time, but I have the right to request child care later.
(Initial and date)

✔ Transportation:
✔ Bus Pass Mileage Parking
p Other (toll fees, taxis, etc.):
p✔ I need advanced payment for transportation.
p I do not need the county to pay for transportation at this time, but I have the right to request transportation later.
(Initial and date)

✔ Advance Student Payments (Required books and supplies)

I do not need Advance Student Payments at this time, but I have the right to request Advance Student
Payments later.
✔ Other ancillary (such as books, tools, uniforms, etc.) costs for:
1. SAAP- Pago de educacion por tiempo 2. parcial. 6 unidades $175

3. 4.

✔ I need advanced payment for ancillary costs.

I do not need the county to pay for ancillary costs at this time, but I have the right to request ancillary costs later.
(Initial and date)

✔ Diaper Payments (I will receive monthly diaper payments for each child under 36 months of age unless I
check the box below indicating I do not need diaper payments.)

✔ I do not need diaper payments at this time, but I have the right to request diaper payments later.

✔ In order to successfully participate in the assigned activities I need the following accommodations (help):
Please specify - for example: special services because of a disability (reading me notices, large print,
special supplies, etc.).
1. N/A 2.

3. 4.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PARTICIPANT’S CERTIFICATION

✔ I understand that my Welfare-to-Work Plan includes this form, the Welfare-to-Work Plan - Rights and Responsibilities,
and the Welfare-to-Work Handbook. I understand that Welfare-to-Work activities and services, and my rights and
responsibilities as a Welfare-to-Work participant, are explained to me on these forms.

✔ I have received a Welfare-to-Work Handbook.

✔ I know I can ask my Welfare-to-Work worker if I have any questions.

✔ I understand that if I tell my county worker that I do not agree with my assessment or the county and I cannot agree on
a plan, the worker must refer me to a neutral third party for a new assessment of my employment or Welfare-to-Work
activity needs.

✔ I understand that I can ask the county at any time for domestic abuse services, including a waiver of certain program
requirements.

✔ I understand that I can ask the county at any time for mental health, substance abuse, or learning disability services.

If this is my first assignment under a Welfare-to-Work plan, I understand that I have 30 calendar days from the date of
my initial Welfare-to-Work Plan to ask for a change or reassignment to another activity. This 30-day grace period is
available only once during my time getting CalWORKs cash aid. If the county agrees to the change, I know I will have
to sign a new Activity Assignment.

✔ I have three (3) working days to think about the terms of this Activity Assignment after I sign it. I understand if I want
to change the terms of this Welfare-to-Work Plan, I must tell my Welfare-to-Work worker by 7/10/2023 .
If I do not tell my Welfare-to-Work worker by then, this Activity Assignment is final. Date

✔ I have read (or had read to me) and understand this Activity Assignment, and have received a copy. If I do not meet
my responsibilities without a good reason, I know that there are penalties that can include having my cash aid
lowered and supportive services may be stopped.

✔ I understand that I can ask for a different service provider if I object to the religious character of any provider to which
I have been assigned.

✔ I understand that I can say no to any religious activity offered by a service provider, and that any participation in any
religious activity offered by a service provider is voluntary.

✔ I understand if I do not agree with any county action regarding my Welfare-to-Work participation, I can file a formal
grievance with the county or I can ask for a State hearing by calling, toll-free, 1-800-952-5253. If the county is
proposing to lower or stop my aid, my aid will not be lowered or stopped if I file a formal grievance.

✔ I understand that I can get free legal help with Welfare-to-Work problems from the local legal or welfare rights office,
by calling (877) 534-2524 .

Participant’s Signature Date

7/5/2023
Welfare-To-Work Worker’s Signature Phone Date
(619) 878-8109 7/5/2023

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State of California ­– Health and Human Services Agency California Department of Social Services

CALWORKS CHILD CARE REQUEST FORM AND CHILD CARE

PAYMENT RULES

NOTICE: You may be eligible for CalWORKs Stage One Child Care
The county pays for child care for children under age 13, and for children up to age 21 with
disabilities.

MY CHILD CARE RIGHTS

• I have a right to receive child care services to help meet my family’s needs. For example:
housing search, domestic violence or mental health counseling, court and medical
appointments, or other similar activities.
• I have a right to child care so that I can go to any Welfare-to-Work (WTW) activity or work.
• My child care will be authorized for 12 months, so that my children get stable, reliable care.
• I have the right to have child care in place before I need to show up for required activities or
appointments.
• I have a right to full-time child care, unless I choose part-time care.
• I have a right to child care as a WTW volunteer, if I choose to participate in activities but don’t
have to.
• If I don’t want child care now, I can ask for it later.

WHO CAN BE MY CHILD CARE PROVIDER?

You can choose who will take care of your child(ren). You can choose a child care center, a licensed
family child care provider, or a family member, friend or neighbor. If you choose a family member,
friend or neighbor, they may need to get fingerprinted. Please see the TrustLine section on the back
of this form.

HOW DO I ASK FOR CHILD CARE?

You can get child care by asking your county worker, at your On-line CalWORKs Appraisal Tool
(OCAT) assessment, or by submitting this form or any request in writing. You should ask for child care
as soon as you know you will need it. Child care will be approved when you get approved for cash aid.

HOW DO I FIND CHILD CARE?

The local Child Care Resource and Referral Agency (R&R) can help you find the best child care
option for your family. You can visit or contact them using the information below, or you can call the
California Resource and Referral Network at: 1-800-KIDS-793.
R&R Agency Name: YMCA Childcare Resource Service Telephone: (800) 481-2151
Address: 4451 30th Street, San Diego, CA 92116 Website: ymcasd.org/crs

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. Do you want child care for any of your children now? Yes ■ No
2. You are eligible for full-time child care (30 or more hours per week). Would you rather have part-
time child care? Yes ■ No
3. Will you need child care if you start working, going to school, training, job search, counseling,
housing search, or other activity? Yes ■ No
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State of California ­– Health and Human Services Agency California Department of Social Services

If you answered No to questions 1, 2, or 3 above:

4. Is somebody watching your children who does not want to get paid? Yes ■ No
5. Are all of your children in Head Start, another free or low-cost child care program, or school?
■ Yes No

Even if you don’t need child care now, you can ask for child care at any time.

CHILD CARE RULES: TRUSTLINE

Your child care provider must be eligible before they can get paid. An eligible provider is a licensed
child care provider, a provider who has cleared the TrustLine fingerprinting and background check
process, or a provider who doesn’t have to get TrustLine registered. If you choose a child care
provider who is required to be TrustLine registered, the county will only pay your provider if they clear
TrustLine. Once your child care provider is TrustLine registered, the county will pay for child care
for up to 120 days from the date you asked for child care or when the child care began, whichever
is later. A grandparent, aunt, or uncle of the child(ren) does not need to be TrustLine registered but
must turn in a form called a Declaration of Exemption from TrustLine Registration and Health and
Safety Self-Certification (CCP1).

TWO-PARENT FAMILIES
In two-parent families, if one parent is able and available to care for the child(ren), the county will
not pay for child care. A parent is considered available to provide care unless they are working (or
sleeping after working), doing a county-approved WTW activity, or have a condition verified by a
doctor, that prevents them from caring for the child(ren).

CERTIFICATIONS Please initial the below certifications.

________ Iunderstand that if I choose a child care provider who is required to be TrustLine registered,
the provider is not eligible for any reimbursement if they do not get TrustLine registered.
________ Iunderstand that I do not have to go to any Welfare-to-Work (WTW) appointment or activity
unless I have found child care that will accept child care payment from the County.
________ Iunderstand that I must tell my worker as soon as I need child care. I understand that I need
to ask for child care within 30 calendar days from the first day I received child care services
for my provider to get fully paid.
________ I SPANISH
have read this notice, or had it read to me in ________________________. If I have any questions
or need additional information about this notice, I can ask my worker.
My worker can be reached at: (866) 262 - 9881.

Case Name Case No.

ALEJANDRINA CORDOVA 1B8V096
Client Signature Date

Case Worker Name Phone

RITA ARCHULETA 619-878-8109
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 County of San Diego Health and Human Services Agency CalWORKs Welfare-to-Work

STUDENT FINIANCIAL AID STATEMENT

WELFARE TO WORK SUPPORTIVE SERVICES
Date: 7/5/23
Welfare-to-Work (WTW) pays for items you need to do Case Name: ALEJANDRINA CORDOVA
your assigned WTW activities or work. These
supportive services are child care, transportation and Case #: 1B8V096
ancillary expenses (such as tools, uniforms, books, or Worker: RITA ARCHUELTA
school supplies) and personal counseling. If necessary Worker Phone: 6198788109
supportive services are not available, you will have
good cause for not participating. I understand that if I agree to use some or all of my
student financial aid for my supportive services:
I understand that I do not have to use any part of • I can change my mind at any time and stop using
my student financial aid (student grant, loan or these funds for my supportive services.
work-study grants) to pay for the supportive
• If I change my mind, the county will again pay for my
services I can get from WTW. supportive services. I must complete Part B of this
form.
I understand that I may choose to use some or all of my
student financial aid to pay for the supportive services • If I change my mind, the county will not pay for the
that I can get from WTW. expenses I agreed to pay before I told the county that
I changed my mind.

PART A: VOLUNTARY USE OF FINANCIAL AID FUNDS FOR SUPPORTIVE SERVICES THAT CAN BE PAID FOR BY
WTW.
 NO. I do not want to use my financial aid to pay for supportive services.
 YES. I voluntary agree to use my financial aid to pay for supportive services, as follows:
 Child Care: $ __________per __________beginning __________and ending __________
 Transportation: $ __________per __________beginning __________and ending __________
 Ancillary: $ __________per __________beginning __________and ending __________
 Counseling: $ __________per __________beginning __________and ending __________
I CERTIFY THAT I UNDERSTAND THIS FORM AND THAT THE ABOVE STATEMENT IS TRUE AND CORRECT.
Participant’s Signature: _________________________________________________________ Date: ___________________
I CERTIFY THAT I INFORMED THE PARTICIPANT THAT USE OF FINANCIAL AID TO PAY FOR SUPPORTIVE SERVICES
THAT CAN BE PAID FOR BY WTW IS VOLUNTARY AND I HAVE PROVIDED A COPY OF THE COMPLETED FORM TO
THE PARTICIPANT.
ECM Signature: _______________________________________________________________ Date: ___________________

PART B: ENDING VOLUNTARY USE OF FINANCIAL AID FOR SUPPORTIVE SERVICES

 STOP. I no longer want to use my student financial aid to pay for supportive services.

I HEREBY CERTIFY THAT THE ABOVE STATEMENT IS TRUE AND CORRECT.

Participant’s Signature: _________________________________________________________ Date: ___________________

The county received Part B on __________________________. You will get a notice telling you what supportive services the
county can pay for. You will also receive a copy of this form when it is completed.

ECM Signature: _______________________________________________________________ Date: ___________________

WTW 8 Student Financial Aid Statement – WTW Supportive Services (09/15)

 My Road Map: Long-Term Goal
ALEJANDRINA CORDOVA
Name: _______________________________ What is your long-term goal that you want to achieve?
What would it mean for your family and you?
1B8V096 Date: ____________
Case #: _____________
7/5/23

REG
CalWORKs Status: _____________________
45 TO COMPLETE CERTIFICATION IN TEACHING AND FIND FULL TIME
Remaining CW Months: _________________
EMPLOYMENT AS A TEACHER
Remaining WTW Months: _______________
RITA-6198781809
ETA Contact: __________________________

Goal Milestone #3:

In order to achieve your long-term goal, what TO PASS SUMMER 2023 SEMESTER
would you need to do first? Then what next? AND ENROLL FOR FALL 2023
Each of these steps are smaller goal milestones Goal Milestone #2:
on the road to your long-term goal.
TO MAINTAIN A GPA OF 3.0 OR
HIGHER TO CONTINUE WITH Possible Roadblock:
EDUCATION
Goal Milestone #1:
ATTEND SCHOOL ON SCHEDULED
DAYS Possible Roadblock: Idea for Detour:
BOOKS NEEDED

Possible Roadblock: Idea for Detour:

TRANSPRTATION ISSUE SAAP

Idea for Detour:

ISSUE PUBLIC
TRANSPORTAION
 My Long-Term Goal:

My Goal Plan REVIEW

Name:
Name: 1B8V096
_____________________________ Case # ___________________ CalWORKs Status: _____________ REVISE
CalWORK
Date: ______________ Remaining CW Months: __________ Remaining WTW Months __________________

Goal Review &

What do I want to do?
What would it mean
Revise
for my family and me? How did it go? What could I do
differently next time?

Plan
Resources Where? Who can help?

What resources do I need?

Where can I get them?

Do I will…

1.
Plan When? Possible Roadblock Idea for Detour

What steps will I take?

When will I do each? 2.

What could keep me 3.

from doing this step?

What can I do to make 4.

sure it happens?

Who will help me stay on track? ___________________________________________________ How? _________________________________________

 FAMILY NEEDS EVALUATION CHECKLIST
CASE CONTACT INFORMATION
Case Number: _______________________________
1B8V096 7/5/23
Contact Date: _______________________________________
ALEJANDRINA CORDOVA
Participant Name: ____________________________ JULY 2023
Report Month/Year: _________________________________

Contact Method: RITA

ECM Name: _______________________________________
✔ Phone ✔ Email Other: ___________________ ES Site:
EQUUS North Coastal EQUUS North Inland
Dates of Attempted Contacts:
7/5/23
PCG Central PCG East ✔ PCG South
ASMT2 COMPELTED
Outcome: ____________________________________
CHECK TYPE OF CONTACT
APR/ASMT/ASMT2/MONTHLY CONTACT/SUPPORTIVE SERVICES EVALUATION/OTHER CONTACT
At each contact, the topics below should be discussed with the customer:
✔ Is your housing situation stable? Where are you staying? How long have you been there?
✔ Do you have past due rent?
✔ Are you having difficulty paying your current rent expenses?
✔ If your rent is being subsidized by the Housing Support Program, are you having difficulty paying your share of
the rent?
✔ Are you moving to a new place and need help with deposit and/or first month’s rent?
✔ If you are homeless, do you need help paying for storage expenses?
✔ Do you need a temporary place to stay?
✔ Do you need help paying for Childcare, transportation, or other needs, such as clothing or school/work
supplies?
✔ Do you need help paying your utility bills?
✔ How are things going with your activity? Are you working, going to school or in a training program?
✔ What are your goals? How can I help you reach your goals?
✔ Is there anything else you need help with? Counseling or other referrals?

ORIENTATION
Elaborate on the HSP and Family Stabilization program benefits and eligibility requirements
Help to cover current rent and utility expenses
Past due rent and utility assistance
Securing permanent housing:
• Security deposit, first/last month of rent, help with past eviction expenses (overdue rent at previous
address, legal fees, etc.), extended housing assistance

DURING ANY CONTACT WITH CUSTOMER

✔ After addressing the customer’s purpose of the call or contact, ask if they need assistance in finding a place to
stay, paying deposit and/or current or overdue rent, deposit and/or current or overdue utility expenses,
childcare, or other supportive services, or and/or referral to BHS/HSP, FS, Legal Aid or other available services
N/A
Comments: __________________________________________________________________________________________
___________________________________________________________________________________________________
ES Staff Signature: _____________________________________________________ Date: ______________________
27-390 HHSA Family Needs Evaluation Checklist