SVdP CLIENT CASE LOG

Person-To-Person Visits & Services
Home Visit / #
Prison Visit / #
Hospital Visit / #
Eldercare Visit / #
Other Location Visit / #
Phone Visit / #
Jobs Obtained / #
Referrals / #
Travel Aid / #
Spiritual Aids Sacraments / #
Other / #
In Kind Goods & Services
Food (# of items from pantry) / #
Direct Delivery Voucher (DDV) / $
Voucher (Clothing/HH Gds) / $
Other
(Per. Care, Baby Care, etc.) / $
Legal Service / $
Medical Service / $
Dental Service / $
Other / $
# of People Helped / 0-18
19-59
60+
Cash Assist from our Conference / $
Anonymous Donation / $
Other Conference ($ amt/who) / $
Initials
Total Time (both visitors combined) / #
Total Miles (both visitors combined) / #
Date of Assist/Visit: / Visitors(Lead):
(Assistant):
Assisted Financially with: (Circle one)
Rent Power Gas Water Oil Propane
Vehicle Gas Medical Pharmacy Dental Auto Repair
Auto-Other (Specify): Other (Specify):
HOUSEHOLD INFO.
Client’s Name: / DOB:
Spouse:
Address: / ¨ Homeless ¨ Other (Shelter, Car, RV, ) Check one only if applies
City: / Zip Code: / email Add:
Phone #: Circle one: Home Cell Message None
ALL OTHERS LIVING AT SAME ADDRESS
NAME / RELATIONSHIP / AGE
INCOME
NAME / SOURCE / TYPE
e.g., wages, SS, WIC, child support, food stamps / AMOUNT
RENT/MORTGAGE
Amount: / Due Date:
Amount of Last Payment: / Date of Last Payment:
How long at current address?
Landlord: / Phone #:
Address:
On Section 8? / How long?
Applied for Section 8? / Date of Application:

SVdP CLIENT CASE LOG

OTHER EXPENSES
TYPE / ACCOUNT # / AMOUNT DUE / DUE DATE
Power
Gas
Water
Medical/Pharmacy
Dental
Car Repair/Tires
Other (Specify)

SVdP CLIENT CASE LOG

REFERRALS to or from OTHER AGENCIES OR CHURCHES
AGENCY/CHURCH / Referred / Assisting ? / How ?
TO / FROM
SVdP ASSISTANCE (as a result of this visit)
TYPE e.g., rent, utility, pharmacy, medical, dental, auto, voucher, in-kind goods, services / AMOUNT / VALUE
OTHER NOTES / COMMENTS
RELEASE OF INFORMATION
I hereby give my permission for these St. Vincent de Paul volunteers to contact other agencies in my behalf.
Signed: / Date: