FSET Intake Form

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 FSET Program, please go to MyFSET.net.

We are looking forward to serving you!
Name *

First Name Last Name
Please share your preferred name if that is different than your legal name.
If you have a preferred pronoun (he/she/they), please let us know.
Email *
example@example.com
Phone Number (primary)

Area Code Phone Number
For the phone number you provided above, please indicate one of the following *

Home Phone Mobile/Cell Phone Message Phone I do not have a phone or message phone
If you are using a message phone, whose phone is it?
What is your county of residence? *
If you were told about FSET by an agency or a person besides the Income Maintenance Consortium, please share who that was.
This institution is an equal opportunity provider.

Employment Search Information
The job I am looking for right now is: *
I am interested in the following career fields (check all that apply) *
Since you selected "OTHER" please tell us what career field you are interested in pursuing.
Please mark all that apply. *
If you have a resume, please upload for your case manager

Browse Files

Cancel of
I am available for the following work shifts: *

1st Shift 2nd Shift 3rd Shift Weekends
My PREFERRED shift/schedule for work is: *
I am enrolled the the following employment program(s): *
This institution is an equal opportunity provider.

Strengths and Resources
Please tell us what you do well.
Please tell us about any other agency who is helping you right now.
We have a list of community resources at www.MyFSET.net. Would you like a printed list of local resources? *

Yes No
Please share if there are things you would like different in your life.
Please type any questions you have for us.
This institution is an equal opportunity provider.