Human Services Center | Supports for Success Interest Form

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First Name *

Middle Initial *

Last Name *

Street Address *

Apartment #, if applicable

City/Town *

State *

Zip Code *

Phone #

Is this a cell phone that can receive texts?

Yes

Email address

Family Size *

8 or more

Required

Approximate Household Monthly Income (to determine eligibility) *

Do you receive food stamps (SNAP)? *

Yes

Required

I am interested in receiving help in: *

Enrolling in school or training

Continuing my school or training

Employment Supports

Finding a better job and/or job search assistance

Improving budgeting and credit management skills

Housing referrals and/or application assistance

Child care referrals and/or application assistance

Health care enrollment (includes medical assistance application assistance)

Food assistance and referrals (includes SNAP application assistance)

Other:

Required

How did you hear about us? *

Supports for Success is funded in whole or in part under the Community Services Block Grant (CSBG) from the Federal Department of Health and Human Services under the administration of the Commonwealth of Pennsylvania, Department of Community and Economic Development. Allegheny County Department of Human Services is the local agency which makes the CSBG funding award.

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