Online Form

Client Intake/Outcome Form

CVM START DATE: CVM END DATE**:

Agency Name*
Agency Security Code* Agency Case Worker Name
Client First Name* Middle Initial Last Name* Suffix (eg, Jr.)
Social Security # (optional) Choose one: Full SSN Partial SSN Don’t know or don’t have Refused
VoiceMail Extension Assigned to this Client* Password (if applicable)

CVM Client Agreement of Understanding

I understand that I have the temporary use of a Community Voice Mail phone number to use ONLY for the purposes and length of time agreed upon by me and the service provider who is giving me this number. I agree to contact the service provider to let him/her know my outcome, whether the voicemail service was helpful, and/or whether I no longer need the voicemail box. I understand that the information in this form will be kept confidential and used only to keep track of CVM services and/or to check CVM eligibility by service providers or funders who have agreed to confidentiality. I understand that the service provider will receive a regular printout on the usage of this voice mail box. This will assist CVM in evaluating the overall effectiveness of the program.

* this field is required.

CLIENT INFORMATION

Age Range (mark one):
under 18
18-25
26-44
45-59
60 and up

unknown

Date of Birth

Ethnicity (mark one):
Non-Hispanic/Non Latino
Hispanic/Latino
Unknown

Race (mark ALL that apply):
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Unknown

Gender: Male Female

Current Monthly Income $

Income Sources (mark ALL that apply):
Earned Income
Unemployment Insurance
SSI
SSDI
Other Disability Income
TANF (or local equivalent)
OWF
Pension/Retirement Income
Child Support
Other Source
No financial resources

Other Characteristics/Situations:
(mark ALL that apply)
Homeless
At Risk of Homelessness
Unemployed
Limited English Skills
Victim of Domestic Violence
Foster Care participant (current or recent)
Parolee/Prisoner Re-entry Program
In-housing – phone disconnected

Veteran Status?   Yes   No
Disabling Condition?   Yes   No

Head of Household?   Yes    No

# of Dependent Children
# of Dependent Adults

If Homeless (mark one):
Living in Emergency Shelter
Living on Streets
Living in Transitional Housing
Doubled up with Family/Friends

CLIENT GOALS & OUTCOMES FOR CVM (circle all that apply)

** leave blank unless you are taking the client off of the system

Exit Reason - What was the primary reason for ending usage/exit? (mark one)**
Client accomplished goals Client abandoned voicemail box Client left agency program or service area
Client reached maximum time limit Other reason:

Exit Question: “How helpful was CVM in achieving the outcome(s)?” **

Very helpful

Somewhat helpful

Not very helpful

Not at all helpful

No information/data available

* this field is required.
** leave blank unless you are taking the client off of the system

When you click the submit button, a confirmation page will appear with the information that you have entered.

From there, you can use the back button on your browser to return to the Community Voice Mail page.

Goal: Employment	Yes No	Outcome: Employment**	Yes No Unknown
Goal: Housing	Yes No	Outcome: Housing**	Yes No Unknown
Goal: Health Care	Yes No	Outcome: Health Care**	Yes No Unknown
Goal: Social Services	Yes No	Outcome: Social Services**	Yes No Unknown
Goal: Safe Communications	Yes No	Outcome: Safe Communications**	Yes No Unknown
Goal: Other Reason(s)	Yes No	Outcome: Other Reason(s)**	Yes No Unknown
Please describe "other reason(s)":