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 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

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  • I am available for the following work shifts:*

  • 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)
  • 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?)*
  • Do you have another current or past job to report?*
  • Do you have another current or past job to report?*
  • Have you done or are you doing any Volunteer or Community Service?*
  • Do you have another Volunteer or Community Service experience to report?*

  • 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*
  • Do you have another college experience to share?*
  • Do you have another certification or license to share?*
  • Do you have another certification or license to share?*
  • 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*
  • Do you have any housing-related concerns?*
  • 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?*
  • Are you currently on probation or parol?*
  • 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?*
  • 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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