Wff Confidential Cover Sheet
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7Washington Families Fund
High Need Family (HNF) Program
Screening Tool
WFF Confidential Cover Sheet
Respondent Name:
____________________________
First and Last Name
Social Security Number:
__ __ __/__ __/__ __ __ __
Date of Birth: __ __/__ __/__ __
O
U
O
FFICE
SE
NLY
I
I
: Please complete the information below prior to administering the tool
NTERVIEWER
NSTRUCTIONS
with the prospective client. These questions do not need to be read to the respondent.
Respondent Study ID:
__ __ __ - __ __ __
*Record Study ID from Program Participation Tracking Form *
Has this respondent’s income eligibility already been verified? ___ Yes ___ No
If no, how and when will it be verified in order to complete eligibility screening?
Date Completed Screening Tool:
__ __/__ __/__ __
Interviewer Name:
__________________
Provider Agency: (circle one) 1. Community Services Northwest
2. Serenity House
3. Sound Mental Health
4. Volunteers of America
5. Women’s Resource Center
6. Abused Deaf Women's Advocacy Services
7. Drug Abuse Prevention Center
8. Walnut Corners
9. Westend Outreach Services
10. Crisis Support Network
11. Valley Cities
12. Yakima Neighborhood Health Services
13. Triumph Treatment Services
14. YWCA
15. West Sound Treatment Services
16. Benton Franklin Community Action Committee
Page 1 of 7 – Prepared by Westat
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