Life Learning Center Candidate Intake Application

Life Learning Center Candidate Intake Application
Referral
Agency/Organization who referred you to LLC: *
Person/Representative who referred you to LLC: *
Identifying Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date *

Month Day Year
Age *
Gender *
Phone Number *

Area Code Phone Number
E-mail
Emergency Contact
Emergency Contact's Name *

First Name Last Name
Emergency Contact Relationship *
Emergency Contact Phone Number *

Area Code Phone Number
Does anyone have legal guardianship over you or your wages? *
Please explain. *
Demographics
Race/Ethnicity *

White/Caucasian Black/African American Asian Hispanic/Latino American Indian Hawaiian/Pacific Islander Biracial/Multiracial
Marital Status *

Single Single Parent Married Separated Divorced Widowed
Highest Level of Education *

No High School Diploma/GED High School Diploma/GED Some College Associates Degree Bachelor's Degree or Higher
Military Service/Veteran *
Household & Family
How many people are in your household? (Insert "1" if you reside in sober living facility) *
Who lives in your household? (e.g. Spouse, children, parents, etc.) *
How many children do you have?
List the gender AND age of your child(ren) *
How many of your children reside in your household? *
Choose the option that best describes your current custody status: *

Full Custody Joint Custody Open Custody Case No Custody Children Over Age 18
What is your personal monthly income? *
What is the source of your personal monthly income? (e.g. employment, child support, SSI/SSDI, etc.) *
Enter N/A if you do not have monthly income
Do you have sufficient income to meet your basic needs? *
What is your monthly household income? (Combined income of everyone in your household) *
What is the source of your monthly household income? (e.g. employment, child support, SSI/SSDI, etc.) *
Enter N/A if your household does not have monthly income
Criminal Background
Do you have a criminal background? *

Are you currently on probation or parole? *
Are you court ordered to attend Life Learning Center? *
Who was the judge who sentenced you to Life Learning Center? *
Housing & Transportation
Select the option that best describes your current housing situation: *

Own or rent home/apartment Residing with family/friends Assisted Housing (Section 8; HUD) Sober Residency Couch Surfing Shelter Homeless/I do not have stable housing
Do you consider your housing to be safe and stable? *
Select the option(s) that best describe your method of transportation *

Drive (have up to date insurance, vehicle maintenance, and driver's license) Bus Family/Friends Walk Uber, Lyft, Taxi, etc. No means of transportation
Do you have a valid driver's license? *
Will you require transportation assistance during your time at LLC? *
Substance Use & Recovery
Do you have a history of substance use? *
What is your sobriety date? *

Month Day Year
Date
Select your substance(s) of choice: *

Alcohol Amphetamines Benzodiazepines Buprenorphine Cocaine/Crack Heroin Inhalants Marijuana Meth/Crystal Meth Methadone Prescription Opioids Suboxone
How old were you when you used drugs/alcohol for the first time? *
What was the first substance you used? *

Alcohol Amphetamines Benzodiazepines Buprenorphine Cocaine/Crack Heroin Inhalants Marijuana Meth/Crystal Meth Methadone Prescription Opioids Suboxone
Select all recovery meetings/treatment programs that you're currently enrolled in: *

Alcoholics Anonymous Medically Assisted Treatment Narcotics Anonymous Celebrate Recovery Intensive Outpatient Program I'm not enrolled in recovery meetings/programs
Did you use controlled substances or see anyone use controlled substances while incarcerated? *
Select the substance(s) you used or witnessed being used: *

Alcohol Amphetamines Benzodiazepines Buprenorphine Cocaine/Crack Heroin Inhalants Marijuana Meth/Crystal Meth Methadone Prescription Opioids Suboxone
Have you ever attended any inpatient or outpatient treatment programs for substance use? (e.g. residential treatment, IOP, jail substance abuse program, etc.) *
List the inpatient/outpatient treatment program(s) you've attended. *
Did you complete the inpatient/outpatient treatment program(s) listed above? *
Health Coverage
Do you currently have health insurance for you and/or your family? *
Is Medicaid/Medicare your health coverage provider? *
Do you have a primary care physician? *
Do you have a usual place to go for healthcare? *
Do you have capacity to manage your health conditions? *
Do you currently have dental insurance for you and/or your family? *
Do you have a usual place to go for dental care? *
Do you currently have vision insurance for you and/or your family? *
Do you have access to mental healthcare? *
Do you rate yourself as being in good or excellent health? *
Do you receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)? *
Physical Health
Check all conditions for which you have been DIAGNOSED with by a health professional: *

Arthritis Body Ailment/Injury Chronic Obstructive Pulmonary Disease Deafness/Hard of Haring Diabetes Epilepsy Fibromyalgia Heart Disease Hepatitis HIV/AIDS Kidney Disease Liver Disease Lupus Narcolepsy Seizure Disorder Spinal Condition/Injury Stroke Thyroid Disease Traumatic Brain Injury Visual Impairment I have not been diagnosed with any physical health conditions

Use the space below to provide any additional information about your physical health status:
When was your last dental exam? *

0-6 months 7-11 months 1 year 2-3 years 4-5 years 6+ years Never
When was your last eye exam? *

0-6 months 7-11 months 1 year 2-3 years 4-5 years 6+ years Never
Are you in need of dental work? *
Are you in need of a vision exam or eyewear? *
Mental Health
Check all conditions below for which you have been DIAGNOSED with by a health professional: *

ADD/ADHD Agoraphobia Antisocial Personality Disorder Anxiety Asperger's/Autism Spectrum Bipolar Borderline Personality Disorder Conduct Disorder Depression Dissociative Identity Disorder Dyslexia Histrionic Personality Disorder Insomnia Learning Disability Obsessive Compulsive Disorder Panic Disorder Post-Traumatic Stress Disorder Schizoaffective Disorder Schizophrenia Social Anxiety Substance Use Disorder I have not been diagnosed with any mental health conditions

Use the space below to provide any additional information about your mental health status:
Have you ever planned or attempted to commit self-harm and/or suicide? *
Explain when you last planned or attempted self-harm and/or suicide:
Have you ever been hospitalized due to mental illness or psychosis? *
Where were you hospitalized and when?
Have you ever experienced or witnessed a traumatic event that was violent, sexual, or life threatening? *
Please explain:
Public Benefits
Select all public benefits you are currently receiving: *

Unemployment WIC TANF (Transportation) SNAP (Food Stamps) Housing (Section 8, HUD, etc.) Medicare/Medicaid Childcare Vouchers SSI/SSDI I do not receive public benefits
Employment
How long have you been unemployed? *

I'm currently employed 0-3 months 4-7 months 8-11 months 1 year 2-3 years 4-5 years 6-7 years 8-9 years 10+ years I have never been employed

Do you have a resume that is accessible and up to date? *
Do you lack job qualifications? (e.g., education, training, experience) *
Do you lack of work history and/or have a gap in employment? *
Pre-Program Self-Assessment

The Life Learning Center program addresses the five domains of life (physical, emotional, relational, financial, and spiritual) to promote hope and dignity amongst Candidates.

Select a 1-5 ranking for each statement below *

Poor

Below Average

Average

Above Average

Excellent

Physical- Rank your knowledge and practice of healthy lifestyle choices including fitness, nutrition, hygiene, and sleep

Emotional- Rank your ability to identify, manage, and employ your emotions

Relational- Rank your understanding of characteristics and boundaries that define a healthy relationship

Financial- Rank your ability to manage your finances and follow a budget

Spiritual- Rank your awareness and practice of personal beliefs to find meaning, connection, and value

Hope- Rank your optimism and enthusiasm for the future

Dignity- Rank your sense of self-worth, value, and importance

Photo Release and Right to Privacy Agreement

By signing below, I consent to the use of my picture or image by the Life Learning Center for the purposes of illustration, advertising, video programming, or publication either alone or in connection with photographs and/or videotape of other persons or objects.

I release all employees of the Life Learning Center from any and all liability of every nature arising from such use.

With my signature, I also acknowledge my understanding that the information requested from me will be used by the Life Learning Center to improve my employment opportunities and change journey. I understand that my personal information may be shared with other partners, providers, and/or employers to enhance my opportunities for growth.
Signature

Clear
Date

Month Day Year
Date
Photo & Media Release
I do grant permission for my picture to be taken, which may be used in news releases, agency brochures, posters, or presentations for publicity for Life Learning Center. I understand my photo may also be taken and distributed to the news media to be used in conjunction with a story about Life Leaning Center. I understand I will receive no compensation and hold the agency harmless. I understand that if, at any time, which I voluntarily speak to any media concerning Life Learning Center, and the services that I receive or perform, that it is confidential in nature and I should not disclose personal and/or confidential information. I also understand that I discharge Life Learning Center from liability in the event that I voluntarily or inadvertently disclose confidential information about myself or others. I do NOT grant permission for my picture to be taken or used in news releases, agency brochures, posters, or presentations for publicity for Life Learning Center. I understand this is purely voluntary.
Signature

Clear
Date

Month Day Year
Date
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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