• FSET Intake Form

  • This information will help us customize services to meet your needs. The information you share will only be seen by the FSET worker who is assisting you in the program and will not be shared with others.

    For more infomation about the NorthCentral and WestCentral FSET Program, please go to MyFSET.net.

    We are looking forward to serving you!

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  • For the phone number you provided above, please indicate one of the following*

  • This institution is an equal opportunity provider. 

  • Employment Search Information

  • I am interested in the following career fields (check all that apply)*
  • Please mark all that apply.*
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  • I am available for the following work shifts:*

  • I am enrolled the the following employment program(s):*

  • This institution is an equal opportunity provider. 

  • Transportation Information

  • Do you have a valid driver's license?*
  • Do you want FSET to help you get a driver's license? (FSET can help with the cost)*
  • Do you have a current Commercial Driver's License (CDL)?*
  • Do you want FSET to help you get a CDL? (FSET my be able to help fund training and the cost of the license)*
  • Do you have a vehicle available for FSET activities and/or work? (FSET can help with the cost of gas)
  • What other ways do you get around? (FSET can help with the cost of bus and taxi tickets)
  • FSET can help with the cost for transportation for FSET-approved activities, education and employment. Please mark supports that you would like help with:

  • This institution is an equal opportunity provider. 

  • Brief Work History

    Please share some basic information about your last three jobs.

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  • Do you have any current or past jobs (including self employment?)*
  • Most Recent Job*
  • Do you have another current or past job to report?*
  • Next most recent job
  • Do you have another current or past job to report?*
  • Next most recent job
  • Have you done or are you doing any Volunteer or Community Service?*
  • Please describe your volunteer/community service experience.*
  • Do you have another Volunteer or Community Service experience to report?*
  • Please describe your volunteer/community service experience.*

  • This institution is an equal opportunity provider. 

  • Education Information

    Please provide information about your education background and education goals.

  • Please mark your high school graduation status*
  • Tell us about your high school*
  • Please tell us where you earned you GED/HSED*
  • Have you completed any type of education or training beyond HS/GED/HSED?*
  • Please tell us about your college experience*
  • Do you have another college experience to share?*
  • Please tell us about your college experience*
  • Please tell us about any certifications or licenses you have earned (if not reported under the College section)*
  • Do you have another certification or license to share?*
  • Please tell us about any certifications or licenses you have earned (if not reported under the College section)*
  • Do you have another certification or license to share?*
  • Please tell us about any certifications or licenses you have earned (if not reported under the College section)*
  • FSET can help with education and training goals and may be able to fund some education and training options. Are you interested in FSET helping you?*

  • For information on education and training opportunites, including free career interest tools, please go to MyFSET.net.

  • This institution is an equal opportunity provider. 

  • Strengths and Resources

  • We have a list of community resources at www.MyFSET.net. Would you like a printed list of local resources?*

  • This institution is an equal opportunity provider. 

  • Challenges

    These questions are voluntary. You can choose to skip any question or section you are uncomfortable giving information. We use these answers to help identify what might affect you achieving your goals and if you need a referral to a social service resource. Please check the following that may be a challenge for you getting or keeping a job. Your answers are confidential and will not be shared outside the program without your permission.

  • Do you wish to complete this Challenges Section? (if you answer yes, you can still decline any part of the section or any specific question)*
  • Have there been any health concerns within the last six months*
  • What type of health concerns?*
  • Please Describe your Physical Health Condition(s)*
  • Please Describe your Mental Health Condition(s)*
  • Please Describe your AODA Challenges*
  • Please tell us more about you caring for someone*
  • Do you have any housing-related concerns?*
  • Please check any housing concern(s)*
  • Do you need any help with these issues or a referral to a community resource?*
  • NorthCentral FSET can sometimes help with a single month rent/mortgage payment or with 1st month's rent if moving into a new place. Did you want your case manager to talk to you about this support service?*
  • Do you have any convictions or pending charges?*
  • Please checkmark any specific issues.*
  • Are you currently on probation or parol?*
  • Please tell us about your probation/parole
  • Do you have any learning-related concerns that affect getting or keeping a job?*
  • Do you have any domestic violence-related concerns?*
  • Do you need any help with these issue or a referral to a community resource?*
  • Do you have a child support order?*
  • Please tell us about your support order(s)
  • As a minor child, did you live with other relatives, foster home or group home?*
  • Did you return to your home before your 18th birthday?*

  • This institution is an equal opportunity provider. 

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