Heaven Sent – Disaster Screening / Triage

Heaven Sent Community Services and Veterans Assistance

Disaster Screening / Triage – Quick Intake

Basic Information

Survivor Name Best Phone Number Alternate Phone or Email (if any) Current Location (shelter, address, landmark)

Disaster and Safety

Disaster type (hurricane, flood, fire, etc.) Is anyone in immediate danger or without a safe place to stay tonight? Describe main damage or loss in one or two sentences

Flags and Priority

Check any that apply (list): Immediate needs today (food, shelter, meds, oxygen, wheelchair, etc.) Referrals already made or agencies already involved (if known)

Staff Use Only (Triage)

Heaven-Sent staff/volunteer name Date and time of contact Recommended next step (open case, refer only, crisis response, etc.)

This quick screening helps us decide how urgently we need to respond and whether a full disaster case file should be opened.

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Heaven Sent – Client Rights & Responsibilities

Heaven Sent Community Services and Veterans Assistance

Disaster Services – Client Rights & Responsibilities

Your Rights as a Client

The right to be treated with dignity, respect, and compassion at all times.[web:959][web:962]
The right to fair, equal access to services without discrimination based on race, color, national origin, sex, gender identity, sexual orientation, age, disability, religion, veteran status, or any other protected status.[web:959][web:962]
The right to have your personal information kept as private as the law allows, and shared only with your consent or when required by law.[web:953][web:961]
The right to receive clear information about what services Heaven Sent can and cannot provide, and what other resources may be available.[web:959][web:966]
The right to ask questions, get explanations you can understand, and receive help with forms and applications.[web:959]
The right to make your own choices about your life, your recovery plan, and whether to accept or decline services.[web:959][web:962]
The right to file a concern or grievance about services or staff and to receive a timely response without retaliation.[web:962][web:967]

Your Responsibilities as a Client

To provide information that is as accurate and complete as possible, and to let us know if your situation changes.[web:959][web:962]
To treat staff, volunteers, and other clients with respect and without threats, abuse, or harassment.[web:959][web:962]
To keep scheduled appointments when you can, or to let us know if you need to cancel or reschedule.[web:959]
To bring important papers when requested (such as identification, insurance, FEMA letters, or lease documents), if they are available.[web:959][web:961]
To ask questions when something is not clear and to participate in your own recovery planning.[web:959][web:966]
To follow basic safety rules in our offices, events, and partner locations.[web:962]

How to Share a Concern or Grievance

If you feel you have been treated unfairly or have a concern about your services, you may tell any staff member, ask to speak with a supervisor, or submit a written concern. We will review your concern and respond as promptly as possible.[web:962][web:967]

You may also request information about how to contact outside agencies if you believe your civil rights have been violated.[web:953][web:967]

Client Acknowledgment

By signing below, I acknowledge that I have received and reviewed this Client Rights & Responsibilities notice. I understand that receiving this notice does not guarantee assistance, but explains how Heaven Sent Community Services and Veterans Assistance will work with me.

Client Name (printed) Client Signature (typed name) Date

Please keep a copy of this notice for your records if possible.

Heaven Sent – Veteran Status & Service Addendum

Heaven Sent Community Services and Veterans Assistance

Veteran Status & Service Addendum

Veteran Identification

Veteran Name (if different from applicant) Relationship of veteran to household (self, spouse, parent, child, other) Date of Birth

Service Information

Branch of Service Service Era (for example: Vietnam, Gulf War, OEF/OIF/OND, Peacetime) Dates of Active Duty Service (if known) Discharge type (if known)

VA and Benefits

Are you enrolled with the VA for health care? Do you currently receive any VA benefits? (disability, pension, education, etc.) If yes, briefly describe your VA benefits Would you like help connecting with VA, DAV, county VSO, or other veteran programs about this disaster?

Authorization to Coordinate Veteran Services

By signing below, I authorize Heaven Sent Community Services and Veterans Assistance to use the information on this form to help connect me with veteran-related services and disaster assistance partners, including VA, DAV, county Veterans Service Offices, and trusted veteran organizations working on emergency and disaster relief.[web:960][web:964]

I understand that this is not a claim form for VA benefits, and that I may need to complete additional VA forms if I choose to apply.[web:964]

Veteran or Applicant Signature (typed name) Date

This addendum is used together with your main disaster application or intake.

Heaven Sent – Disaster Case File

Heaven Sent Community Services and Veterans Assistance

Disaster Case File – Recovery Plan, Case Notes, and Housing/Shelter Intake

Section 1 – Client and Case Header

Client / Survivor Name Case Number (assigned by Heaven Sent) Primary Case Manager Open Date Disaster Name / Event (for example: Hurricane & Year)

Section 2 – Disaster Housing / Shelter Intake

Where did the client sleep the night before first contact? Current living situation How long displaced from original home? (days / weeks / months) Risk factors related to housing (check or describe) Landlord or property contact (if applicable)

Section 3 – Recovery Plan Overview

Use this section to record the survivor’s main goals and the steps everyone agrees to take. Update this page as progress is made or needs change.[web:959][web:966]

Survivor’s own words about their main goals after this disaster Key strengths and supports (family, faith community, income, skills, etc.) Barriers to recovery (health, finances, transportation, documents, legal issues, etc.) Overall priority level for this case (low / medium / high / crisis)

Section 4 – Recovery Plan Goals and Actions

List specific goals, what needs to happen, who is responsible, and target dates. You may copy and add more rows as needed.[web:959][web:962]

Goal #	Goal (what outcome we want)	Actions / Tasks	Who is responsible?	Target date	Status / Notes
1
2
3

Section 5 – Case Notes and Contact Log

Record each meaningful contact with the client or on behalf of the client: date, type of contact, summary, and next steps. This helps with continuity and audits.[web:959][web:962]

Date	Type (phone, in-person, email, text, meeting)	Person contacted	Summary of discussion / action taken	Next steps / follow-up	Staff initials

(You may copy and add more rows for additional contacts.)

Section 6 – Case Closure

Closure Date Reason for closure Closure summary and key outcomes

This case file is intended for internal use by Heaven Sent Community Services and Veterans Assistance and trusted partners who are directly involved in the client’s disaster recovery, consistent with consent forms on file.[web:959][web:962]

Heaven Sent – Disaster Case File