Hand-Up Program Application | Second Chance Society

Section A: Referring Agency Information

Date of Application*

Referring Agency Name*

Referring Agency Address*

Building or Suite #

Case Manager Name*

Case Manager Email*

Case Manager Phone Number*

Section B: Client Information

Client Name*

Client Address*

Apt/Suite #

Client Phone Number*

Client Email*

Client Date of Birth*

Client Age*

Client Marital Status*

Client Gender at Birth*

Client Race*

Client Ethnicity*

Last 4 Digits of Client's SSN*

Client's Education Level*

Is client a military veteran?*

Yes

Does client have health care?*

Yes

Does client have a disability?*

Yes

Does client receive TANF?*

Yes

Does client have an arrest record?*

Yes

Has client been to prison?*

Yes

Housing Type*

Housing Composition/Arrangement*

Number of Adults*

Number of Children*

Household Income*

Client currently employed?*

Yes

Monthly Income*

Employment Type*

Employment Length (# of months)*

Able to contact Employer?*

Yes

Employer Contact Information*

Emergency Contact Information*

I've been feeling optimistic about the future:*

None of the time

Rarely

Some of the time

Often

I've been feeling useful:*

None of the time

Rarely

Some of the time

Often

I've been feeling relaxed:*

None of the time

Rarely

Some of the time

Often

I've been dealing with problems well:*

None of the time

Rarely

Some of the time

Often

I've been thinking clearly:*

None of the time

Rarely

Some of the time

Often

I've been feeling close to other people:*

None of the time

Rarely

Some of the time

Often

I've been able to make up my mind about things:*

None of the time

Rarely

Some of the time

Often

Employment Barriers*

Lack of housing

Lack of income

Expired work license/certification

Lack of training

Lack of work clothing

Lack of work tools

Client's Personal Testimony*

Client's Work History*

Client's Education History*

Client's Request*

Request Type*

Case Manager Recommendation*

Client's Signature*

I understand and agree that the story of my success through the Second Chance Society Hand-Up Program may be shared by Second Chance Society with others, printed, published or otherwise disseminated. I understand that any such revelation or publication shall be done in an anonymous manner, without identifying me by name, unless I specifically agree that my name may be used.

Case Manager's Signature*

I am the Case Manager who has referred the above client to Second Chance Society for their assistance. I acknowledge that the client has authorized me and my agency to periodically release information to Second Chance Society regarding the client’s employment and living situation for a period of up to one year from the date of award any goods or services from Second Chance Society to the client.

Hand-Up ProgramApplication Form

Section A: Referring Agency Information

Section B: Client Information

Hand-Up Program
Application Form