Transition to Success and Network of Care Intake Form

Please complete this intake to enroll in the Helpline Center Network of Care and Transition to Success (TTS) program. We will respond within 2-3 business days.

*If you need immediate help, please call one of the following:

211 for community resources
988 for mental health needs
911 for life and safety concerns

This program is for residents of South Dakota. Does the person enrolling live in South Dakota?*

YesNo

This program is only for residents of South Dakota. Please call 211 for help searching resources in your local area.

Are you completing this intake for yourself or someone else?*

MyselfSomeone Else

Name of the Person to Enroll:*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

May we leave a voicemail at this number?*

YesNo

May we text this number?*

YesNo

Date of Birth*

Date

Gender*

Race / Ethnicity*

Currently experiencing homelessness?*

YesNo

What is the current living situation?

Place not meant for habitation (e.g. a vehicle, abandoned building, non-living spaces in a building, bus/train/subway station/airport or anywhere outside)Emergency shelterHotel or motel that is majority paid with an emergency voucherRunaway and Homeless Youth Host Home ShelterOther

If in the Sioux Falls area, would you like to request a homeless voucher referral?

YesNoMaybe, please call me first

Would the person enrolling want a follow up phone call from a TTS Coach?

YesNoNot right now but in the future

When you would like a Coach to reach out

Address:*

Street or Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please rate each Life Area on a scale of 1 to 5. Select 0 if this Life Area does not apply.*

	1 - In Crisis	2 - Need Help Soon	3 - Could Be Doing Better	4 - Doing OK	5 - Doing Really Well	0 -Does Not Apply to Me
Food
Housing
Money
Mental Health
Drugs / Alcohol
Health Care / Insurance
Safety
Transportation
Disabilities
Life Skills
Work
Legal
Adult Education
Child Care
Parenting
Children Education
Community Involvement
Support from Family & Friends
Budgeting
Discrimination / Racism
Internet / Phone
Dental Care
ID / Birth Certificate

What is your main dream for your life right now?

Please provide additional information that the TTS Coach should know about the person enrolling:

Consent Instructions:

Please review the Helpline Center Network of Care consent and release of information below.

If you are enrolling someone else, the person you are enrolling must agree to the consent and type their name themselves below.

Helpline Center staff only may collect a verbal signature.

Is this referral from a Helpline Center staff?

YesNo

Helpline Center Verbal Consent - Please read consent below.

Client verbally consented

Helpline Center Network of Care Consent

You understand the collection and use of all your personal information is protected by strict standards of confidentiality as outlined in writing in the Helpline Center Network of Care Policies and Procedures. Please review the full consent here. You understand that your personal information will only be disclosed in accordance with applicable South Dakota laws.

Do you consent to share your information with the Helpline Center Network of Care?

YesNo

Electronic signature: Please type your full name

First and Last Name

Today's Date*

Date

Name of person completing this form:

First NameLast Name

Email of the person completing this form:

example@example.com

Organization:

Phone Number

Please enter a valid phone number.

Is the person you are enrolling receiving ongoing case management?

YesNo

Transition to Success Intake Form