__________ Church,___________,N.Y.

AssistanceRequestScreeningForm

Date:____________Time:_____________Informationtakenby:______________

NameofCaller:_____________________________________________________
ContactPhoneforcallback(somecallswillrequireadecisionfollowing
consultationwithpastororotherresearch):______________________________
Request:___________________________________________________________
___________________________________________________________________

Meetsthefollowingcriteriaorresourcesavailable:

Liveswithinservicearea......... .[]yes[]no
Resourcecurrentlyavailable........[]yes[]no
Parishionerorrelated..............[]yes[]no
Churchhasministryaddressingneed[]yes[]no
..........[]yes[]no
..........[]yes[]no
..........[]yes[]no
..........[]yes[]no

Churchisabletoassistwithintheiravailableministries/services:[]yes[]no

Ifyes,ServicesProvided:____________________________________________

Ifno:
ReferredtoCatholicCharitiesifapprovedbypastor[]yes[]no
NameofCCstaffreceivingthereferral_______________________________________

ReferredtoOtherPrograms:____________,______________,_________

Persontoldthatservicesarenotavailable[]yes,[]no

FollowupNeeded:[]no.[]yes:____________________________________

AdditionalInformation:

Filereportandlognameandcontactinformation
DRAFT to be adapted by each Parishs situation. CC PPP 1-18-12