VCP Intake Form (Rev 2 for 2022)

Volunteer Center of Whatcom County/Opportunity Council- Volunteer Chore Program

Phone: (360) 734-5121 ext.1172 Fax: (855) 224-7921 chore@whatcomvolunteer.org

VCP Client Intake Form 2022

Referral Information

Date(Required)

Month

Day

Year

Agency(Required)

Referrer First Name(Required)

Referrer Last Name(Required)

Referrer Phone Number(Required)

Referrer Email if Available

Client Information

Client's First Name(Required)

Client's Last Name(Required)

Date of Birth(Required)

Month

Day

Year

Client Age

Client's Address(Required)

City(Required)

State(Required)

Zip(Required)

Gender(Required)

Male

Female

Other

# in Household(Required)

# In household over 60(Required)

Client Phone(Required)

Client's Email Address (If Available)

Ethnicity (Select Only One)(Required)

Hispanic/Latino

Not Hispanic/Latino

Race(Required)

Preferred Language if Limited English

Does Client Smoke?

Yes

May Volunteers Bring Kids?(Required)

Yes

List Any Pets

Military Status(Required)

Veteran

No Military Service

Unknown/Not Reported

Has client asked family and friends for assistance?(Required)

Yes

Please explain support client is currently receiving from family and friends.(Required)

Physical Assessment (Disability preventing client from completing requested task or tasks)(Required)

Emotional Assessment (i.e. anxiety, depression, bi-polar, friendly)(Required)

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone #

Services Requested(Required)

Dog Walking

Contact-less Shopping

Yard Work

Communication

Repairs/Construction

Medical Transportation

Other

Please Note: All services provided on a limited basis depending on volunteer availability.

What services does the client need?(Required)

Comments

Client gives consent to referral(Required)

Yes

Client understands volunteers cannot be compensated for their time. If client wishes to make a contribution he/she can donate to the Chore Program directly.(Required)

Yes

Client agrees to treat volunteers with respect, observe boundaries and contact the Chore Program if problems arise(Required)

Yes

Client understands referral information is confidential unless the Chore Program is concerned for client’s safety. Client authorizes the Chore Program to exchange information as necessary for the purpose of obtaining services (i.e. Adult Protective Services, medical provider, referring agency)(Required)

Yes

Client agrees a screened and selected volunteer can contact him/her directly(Required)

Yes

Client is a veteran requesting transportation assistance and will need additional paperwork sent, including DD-214 and proof of income (i.e. DSHS food stamps award letter).(Required)

Yes

DD214 and Proof of Income

Drop files here or

Max. file size: 25 MB.

Income Verification

Documentation is not required unless requested. Please select which type of documentation the client would provide if asked.

Do you have any income?(Required)

Yes

What sources of income do you have?(Required)

Wages

Other Salary Income

Business Income

Self-Employment

Interest Income

Dividend Income

Pension

Retirement Income

Unemployment Income

Disability Income

TANF

Other Public Assistance Income

Monthly Income(Required)

For documentation and verification purposes client is required to sign a self-declaration of no income form. Chore staff will mail client the form.

SUBJECT: Verification of information supplied by an Applicant for assistance in the home.

This person has applied for assistance with basic essential needs in their home to help continue living independently. Our funding through the City of Bellingham requires the Volunteer Chore Program to verify a disability for anyone under the age of 60 applying for services.

We ask for your cooperation in providing the following information and returning it to the person listed at the top of the page. Your prompt return of this information will help to ensure timely processing of the application for assistance. The applicant has consented to this release of information as shown below.

CLIENT RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.

Disability Verification for Clients Under 60

Name of Medical Professional(Required)

Organization of Medical Professional(Required)

Address of Medical Professional(Required)

Client Release Acknowledgment

Check to acknowledge that you have read and agree to the client release information above.

Date

Month

Day

Year

Area to be completed by a Medical Professional

For each numbered item below select the option that accurately describes the person listed above.

1. Has a disability, as defined in 42 U.S.C. 423, which means;

Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months; or
In the case of an individual who has attained the age of 55 and is blind, inability by reason of such blindness to engage in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he/she has previously engaged with some regularity and over a substantial period of time.

Medical Professional Q1

Yes

2. Has a physical, mental, or emotional impairment that:

Is expected to be of long-continued and indefinite duration;
Substantially impedes his or her ability to live independently; and
Is of such a nature that the ability to live independently could be improved by assistance in their homes with essential basic services.

Medical Professional Q2

Yes

3. Has a developmental disability as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act 42 U.S.C. 6001 (8), i.e., a person with a severe chronic disability that:

Is attributable to a mental or physical impairment or combination of mental and physical impairments;
Is manifested before the person attains age 22;
Is likely to continue indefinitely;
Results in substantial functional limitation in three or more of the following areas of major life activity: (1) Self-care, (2) Receptive and expressive language, (3) Learning, (4) Mobility, (5) Self-direction, (6) Capacity for independent living, and (7) Economic self-sufficiency; and
Reflects that person’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.

Medical Professional Q3

Yes

4. Is experiencing a temporary physical or mental impairment that is affecting their ability to perform basic essential tasks that are critical to maintaining their independence. If so, what is the expected duration?

Medical Professional Q4

Yes

Expected duration:

Unique ID