l;jkl;kjl;jk
l;jkjklklj
jlkj;ljk;lkj
Case Name:____________________________________________Caseworker:______________________________Date:______
State of Illinois
Department of Human Services
RESOURCE CONNECTIONS
lkjl;kjl;jk
jk;lkjl;jklkj
First Name
Last Name
l;kjl;jkl;jk
l;kj;ljk;ljk
Middle Initial Case ID Number
The services we discussed that may be helpful to you are checked below.
Family Connections
___
Apply for SSI/SSA , Veteran’s benefits, Workman’s Comp, Unemployment benefits (Circle
one) You will need the following types of application information: birth certificate, social
security card, etc. (Condition of eligibility - medical benefits and TANF).
✔
___
Contact food pantry, for help with groceries.
✔
___
Contact the local housing authority.
✔
___
Check classified, Realtor, rental agencies, bulletin boards, etc. for housing.
✔
___
Contact township for rent and utility assistance (Cook county only).
✔
___
Check on homeowner assistance programs.
✔
___
Contact and sign-up with a family doctor.
✔
___
Discuss with physician/pharmacist how medication interacts.
✔
___
Bring in medical receipts to meet spend down requirement.
✔
___
Check on and arrange for home health care.
✔
___
klhklhjkljh
Make an appointment and go/meet for:__________________________________
(ex. advocates, caseworker, counselors, dentist, eye exam, family planning,
immunizations, ongoing health care, prenatal care, physical, school officials, Teen
Parent Services, WIC, etc).
✔
___
kljhlkhjlkh
Look into:______________________________________________________
(ex. adult day services, early intervention, homemaker services, respite care,
transportation, etc.).
✔
___
lkjl;kj
Check into participating in:________________________________________________
(ex. adopt a grandchild, after school, Boys/Girls Club, counseling, meals on wheels,
parenting, senior groups, support groups, etc.).
✔
___
;kljljkk
Contact Senior Center for:_______________________________________________
✔
___
Obtain help from attorney/legal aid/state’s attorney
(ex. child support, DCFS, domestic violence, elderly issues, eviction, etc.).
___
Contact DPA /DCSE for help with obtaining child support and/or establishing paternity
(Condition of eligibility - medical benefits when appropriate and TANF)
The Resource Connections Checklist is given to you as a summary of our talk today. It in NO way affects eligibility for
AABD, medical, or food stamp benefits.
(Attach copies of any referrals made to this plan)
IL444-4004 (N-2-00)
E
l;jkl;kjl;jk
l;jkjklklj
jlkj;ljk;lkj
Case Name:____________________________________________Caseworker:______________________________Date:______
Employment, Education, Training Connections
✔ College
✔ Community Service/Volunteer __
✔ Adult Education __
Check the activity the individual t will be working on: __
✔ Vocational training
✔ Employment __
✔ GED __
✔ Job Skills Training
✔ High School
✔ Self-employment
✔ ESL __
__
__
__
__
✔
___
Enroll in an educational program (ex. ABE, GED, ESL, business, college, vocational).
✔
___
Enroll in employment related workshop (resume writing, job skills, writing business plan).
✔
___
Contact job center about employment opportunities.
✔
___
Contact area employers about employment opportunities for retirees.
✔
___
Check with Senior Employment Services (age 55 & older).
✔
___
Share trade skills with others (ex. retiree shares skills at comm ctr, school, job club).
✔
___
Contact community college to participate in community enrichment classes.
Treatment Connections
✔
___
Contact support groups (Al Anon, AA, Emotions Anonymous, etc.)
✔
___
Notify DHS or Mental Health provider if unable to get needed medication
✔
___
;lk;lkj
Contact: ____________________________to
develop a safety plan
✔
___
jkl;;lkj
Contact: ____________________________to
obtain an order of protection
✔
___
klj;lkjj
Contact: ____________________________if
unable to participate in recommended treatment.
✔
___
;klkjljk
Contact: ____________________________to
schedule an appointment for
✔
✔
✔
__domestic violence
__ mental health
__substance
abuse
Other
✔
___
✔
___
✔
___
;lkj;jkl
kl;jlkj;l
;lkj;ljkk
NOTES
Record discussions, observations, referrals below. Use INFORMATION ON CASE HISTORY (IL444-0514) for further
comments.
kj;lkj;ljk;lj;
(Attach copies of any referrals made to this plan)
Print
Reset Button