STEP Service Navigation

STEP Service Navigation - WZ Referral

General Registration & Assessment Questionnaire
Referral:
Name*

First NameMiddle Name or InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Primary Phone*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number

Other than yourself, how many individuals are in your household?

Service Assessment Questionnaire

These answers will help us match you with appropriate services at STEP and the community.
Current Service Provision
Are you currently receiving STEP services?

NoYes
What STEP services are you receiving?
Are you currently receiving services through another agency in the community?

NoYes
What agencies are you receiving services through?

Transportation
Do you need dependable transportation?

No - I have dependable transportationYes - I do not have dependable transportation
Check all that apply:

I am unable to work due to no transportation or unreliable transportationI am unable to attend medical appointments due to no transportation or unreliable transportation

Education
Do you have a high school diploma or GED?

NoYes
Are you seeking education funding for current student loans or future education expenses?

NoYes
Are you interested in improving your reading, writing, math, or digital literacy skills?

NoYes
Are you interested in attending either college or a vocational training program?

NoYes

Health Care Providers
Are you in need of a primary care provider?

NoYes
Are you in need of a dental provider?

NoYes

Independent Living (Age 60+)
Are you 65 years or older?

NoYes

Other
Are you looking for volunteer opportunities?

NoYes
Do you have any additional needs which were not discussed within this questionnaire?

NoYes
What are those additional needs?

Application and Release of Information Signature
The information provided in this application packet is complete and accurate to the best of my ability. I authorize STEP, Inc. to exchange, with other agencies and STEP programs, any inofrmaiton that is pertinent ot the delivery of services requested or potentially available. A copy of this authorization shall be considered valid.

This release is effective while receiving services through Service Navigation not to exceed one year.
Date*

MonthDayYear
Date
Signature*
Grievance Process
If you are determined ineligible through the Service Navigation General Registration (Community Service Block Grant) and disagree with this decision, you have the right to appeal. To appeal this decision, please submit your reason for disagreement along with your name, address, and telephone number in writing to Raelyn Jackson, at 2138 Lincoln Street, Williamsport PA 17701 or to rejackson@stepcorp.org. Your appeal will be mailed within 14 calendar days of receipt.
Do you have income in your household?

YesNo
If you have household income, please select "yes" and upload proof of your income for the last 30 days in the upload below.

If you have not had household income for the last 30 days, upon submitting this form you will be automatically redirected to the brief "Claim of Zero Income in Household" form. Please complete and submit.

Your application cannot be processed without either proof of income or the Claim of Zero Income form.
Please provide documentation of household income for the last 30 days.

Ex.: pay stubs, Social Security benefit letters, TANF documentation, etc.
Cancelof
Should be Empty:

STEP Service Navigation - WZ Referral

Service Assessment Questionnaire

Application and Release of Information Signature

Grievance Process