FSC Intake Paperwork Form

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Knowledge Quest Application: Family Stability Center

Please fill out this application carefully and double check to ensure that all information provided is accurate and correct (including spelling).

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Date

PRIMARY APPLICANT

Provide your name and contact information. Please check for accuracy before proceeding to the next section.

Name*

First Last Optional: Sr., Jr., III, etc.

Date of Birth*

Gender*

Male

Female

Other

Prefer not to answer

Race*

African American or Black

Caucasian or White

Asian

Native American

Other

Prefer not to answer

Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Home Address*

Street Address Apartment # City State ZIP Code

Phone Number:*

Email:

Additional Information

Veteran*

Relationship Status*

Education Level:*

Employment Status*

Employer Name*

Job Title or Position

FAMILY AND HOUSEHOLD COMPOSITION

Additional Adult(s) in Household?*

If yes, how many?

Children In Household

Please separately add information for each person living in the household under the age of 18.

Relationship to You*

Add a row for each additional child

First Name

Last Name

Date of Birth (mm/dd/yyyy)

Gender (M/F)

PROGRAM PARTICIPATION AND CONSENT

PARTICIPANT RESPONSIBILITIES

Meet with the assigned FSC team member for an initial assessment, as well for any additional appointments in person and/or by telephone as determined and identified in my individualized service plan. At least one home visit will be required on a monthly basis (all other contacts may be by phone/text, email, and/or program participation).
Make a commitment of being involved in the FSC program for up to three months of active case management services and nine months of follow-up / sustainability monitoring services.
To work with the assigned FSC team member in the development of an individualized CARE Plan to help meet my goals towards self-sufficiency (“becoming anchored”) as well as for the stability of my household.
Participate in any recommended workshops, “family circles”, and individual trainings on topics (such as Financial Literacy, Time Management Skills, Parenting and Employability Skills).
Always remain “actively engaged” with the program, which includes regular communication with my assigned case worker, keeping them abreast of my contact information, and displaying a genuine interest in my own investment toward meeting my identified goals.

The above guidelines and conditions must be met in order to remain eligible for the Family Stability Center Program. All resources will be provided based upon availability and suitable eligibility.

Signature*

Name*

First Last

Date*

AGENCY RESPONSIBILITIES

By agreeing to engage with the above identified participant, Knowledge Quest, through its Family Stability Center (FSC) Program will adhere to and honor the following:

To provide participants with a comprehensive provision of case management services and support, based on the specific needs/goals of the participant.
The appropriate and timely referral of needed resources not directly provided by Knowledge Quest.
The provision of valuable, informative trainings / workshops / seminars both on site and off, designed to help strengthen individuals and their families.
The provision of resources (or referral for resources) to address basic needs (such as food, clothing, housing) as well as those addressing needs related to social / emotional / physical health and economic empowerment.

Further, Knowledge Quest/FSC is committed to honoring the dignity and respect of all those enrolled in the FSC program. To this end, the agency will adhere to established policies related to client privacy, as noted in the attached “Confidentiality Statement”.

Signature*

Name*

First Last

Date*

Client Notice of Rights / Confidentiality Form

Knowledge Quest
Family Stability Center (FSC)

Client Notice of Rights / Confidentiality Form

As a client of the Family Stability Center Program (FSC), you have the following rights regarding the confidentiality of your personal information and communications with FSC staff and volunteers:

The information that you provide to FSC will be kept confidential to the greatest extent allowed by law.
You may choose what information you want to provide to FSC, however you will be advised of information essential for the determination of eligibility for service provision.
The information that you provide to FSC, including your name, address, phone number, and other personal information will not be shared with other individuals or agencies without your expressed written / documented permission.
FSC staff may be required by law to report certain situations. Very specifically, this includes the state’s mandate to report suspected child abuse or neglect. Other issues in which the FSC staff are mandated to report include situations which would constitute a threat to yourselves or to others, elder or vulnerable persons abuse and / or commission of a crime or illegal activity.
General, non-identifying information about the types of services provided and overall demographics, (e.g. age and income ranges, average number of children, ethnicities) of program participants may be shared with the agencies and other entities that fund or support the program in various ways. However, information that specifically identifies you as a program participant, or anything related to you personally, cannot be shared publicly without prior authorization from you.

For the growth of the program to better serve its participants, there may be occasions when more details may need to be shared to promote the impact of the work. In these instances, you would be asked to sign a separate “consent / media release form”. You reserve the right to honor such a request, or not.

After your intake with the FSC program, you may be referred to other agencies for additional collateral services and support. It is the procedure of FSC to make that referral a “warm hand-off” (i.e. FSC staff will make a personal connection to referral agencies prior to a participant making contact, for a more efficient referral process). Those respective agencies will review their respective policies regarding confidentiality and consent issues during the intake phase of those programs.
FSC utilizes CaseWorthy system for data collection, referral tracking, and case management information. All participants of FSC will have their information entered into this system. Information in the system is only accessible to entities who have authorized consent to receive / view client information.
Any questions or concerns about this notice or your rights and matters of confidentiality, or if you have a concern that your confidential information was not treated appropriately, please contact the FSC Program Director at 901-681-8264, located at the program site (1044 South Third Street, Memphis, TN 38106).

Signature*

Name*

First Last

Date*

Thank you!

We will be in contact soon. Verification of this information and/or further information may be required.

FSC Intake Form

Family Stability Center - Initial Intake Paperwork

Section Break

Knowledge Quest Application: Family Stability Center

PRIMARY APPLICANT

Additional Information

FAMILY AND HOUSEHOLD COMPOSITION

Other Adult (1)

Other Adult (2)

Children In Household

PROGRAM PARTICIPATION AND CONSENT

PARTICIPANT RESPONSIBILITIES

AGENCY RESPONSIBILITIES

AGENCY RESPONSIBILITIES

Client Notice of Rights / Confidentiality Form

Knowledge Quest
Family Stability Center (FSC)

Client Notice of Rights / Confidentiality Form

Thank you!

Gaston Park Campus

College Park Campus

Main Campus

FSC Intake Paperwork Form

FSC Intake Form

Family Stability Center - Initial Intake Paperwork

Section Break

Knowledge Quest Application: Family Stability Center

PRIMARY APPLICANT

Additional Information

FAMILY AND HOUSEHOLD COMPOSITION

Other Adult (1)

Other Adult (2)

Children In Household

PROGRAM PARTICIPATION AND CONSENT

PARTICIPANT RESPONSIBILITIES

AGENCY RESPONSIBILITIES

AGENCY RESPONSIBILITIES

Client Notice of Rights / Confidentiality Form

Knowledge QuestFamily Stability Center (FSC)

Client Notice of Rights / Confidentiality Form

Thank you!

Gaston Park Campus

College Park Campus

Main Campus

Knowledge Quest
Family Stability Center (FSC)