PSM Monthly Report Dates: only complete when the outreach center is open.

Persons served (unduplicated): Age: Child 0-18 Adult 19-64 Senior 65+ Total persons Gender: Male Female Total persons Race/ethnicity: Black White Hispanic Other Total persons

Parish: Month: 1 2 3 4 5 6

Year: 7 8

Parish Social Ministry Monthly Report Parish code: Deanery: Town: 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Services or referrals provided: 1 Day Care 2 Economic assistance 3 Food 4 Health care info & advocacy 5 Housing 6 Immigration 7 Information and referral 8 Advocacy 9 Transportation 10 Substance abuse 11 Informal counseling 12 Basic needs of living 13 Employment 14 Legal 15 Other Total services/referrals 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Other Information: 1.) Of all the persons served this month, how many were new this year (since Sept.1)? 2.)How much financial assistance have you given this month directly from Parish Sources? (Please exclude all Catholic Charities contributions.): $ 3.) List the three unmet needs requested most often this month: a) b) Completed by Date Phone

c)

120452496.xls.ms_office

Form revised: May,2009