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: *
Contact 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
Gender *
Phone Number *

Area Code Phone Number
E-mail *
Social Security Number *
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? *
If answered "Yes" to the question above, 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? *
Who lives in your household? *
How many children do you have? *
List the gender and age of your children
List the race of your children
How many children reside in your household? *
Will you require childcare assistance during the LLC program? *
Choose the option that best describes your current custody status: *

Full Custody Joint Custody Visitation Open Custody Case No Custody Children Over Age 18 N/A- I do not have children
Does at least one member in your family identify as a race other than Caucasian? *
Is at least one member in your family a U.S. Veteran or active military? *
What is your total monthly household income? *
What is the source of your monthly household income? (e.g. employment, child support, SSI/SSDI, etc.) *
What is your total monthly personal income? *
What is the source of your monthly personal income? (e.g. employment, child support, SSI/SSDI, etc.) *
Criminal Background
Do you have a criminal background? (If yes, complete the table below) *

Beginning with your most recent charge, complete the following regarding your criminal history:

Month & Year of Conviction

Felony or Misdemeanor

Description of Charge/ Conviction

State & County

Charge #1

Charge #2

Charge #3

Charge #4

Charge #5

Charge #6

Charge #7

Charge #8

Charge #9

Charge #10

Are you currently on probation or parole? *
Alternative Sentencing? *
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 stable and secure? *
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
Will you require transportation assistance during your time at LLC? *
Do you have a valid driver's license? *
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 Cocaine/Crack Heroin Inhalants Marijuana Meth/Crystal Meth Prescription Opioids N/A- I do not have a history of substance use
At what age did you first engage in substance use? *
What was the first substance you used? *

Alcohol Amphetamines Benzodiazepines Cocaine/Crack Heroin Inhalants Marijuana Meth/Crystal Meth Prescription Opioids N/A- I do not have a history of substance use
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 N/A- I do not have a history of substance use
Did you use controlled substances or see anyone use controlled substances while incarcerated? *
Have you ever attended any inpatient or outpatient treatment programs for substance use? *
If answered "yes" to the question above, please list the inpatient/outpatient treatment program(s) you've attended AND whether you completed them.
Health Coverage
Do you currently have health insurance for you and/or your family? *
Do you currently have dental insurance for you and/or your family? *
Do you currently have vision insurance for you and/or your family? *
Do you have a primary care physician? *
Do you receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)? *
Physical Health
Check all that apply to your physical health: *

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

Complete the following for all physical health conditions selected above:

Physical Condition

At what age were you diagnosed?

Are you receiving treatment for this condition from a doctor or physician? If so, explain.

List all medications you are currently taking for this condition

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 that apply to your mental health: *

ADD/ADHD Agoraphobia Antisocial Personality Disorder Anxiety Asperger's/Autism Spectrum Bipolar Borderline Personality Disorder Conduct Disorder Cyclothymic Disorder Depression Dissociative Identity Disorder Dyslexia Histrionic Personality Disorder 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:

Complete the following for all mental health conditions selected above:

Mental Condition

At what age were you diagnosed?

Are you receiving treatment for this condition from a doctor or counselor? If so, explain.

List all medications you are currently taking for this condition

Have you ever attempted or planned to commit self-harm and/or suicide? *
If answered "yes" to the question above, explain when you last planned or attempted self-harm and/or suicide:
Have you ever been hospitalized due to mental illness or psychosis? *
If answered "yes" to the question above, where were you hospitalized and when?
Have you ever experienced or witnessed a traumatic event that was violent, sexual, or life threatening? *
If answered "yes" to the question above, 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? *
Do you lack qualifications/work experience? *
Do you have a lack of work history and/or a gap in employment? *
Select all job industries that you have previous work experience in: *

Administrative/Clerical Architecture & Construction Arts Automotive Business Management Customer Service Finance Food Service Health Care Hospitality Human Services Information Technology Labor & Manufacturing Logistics Marketing & Sales Public Safety Retail Science Technology Trade- Welding, Electric, Plumbing Transportation I have no work experience
What companies have you worked for within the industries listed above? *
Select the job industry that you would like to pursue next: *

Administrative/Clerical Architecture/Construction Arts Automotive Business Management Customer Service Finance Food Service Health Care Hospitality Human Services Information Technology Labor & Manufacturing Logistics Marketing & Sales Public Safety Retail Science Technology Trade- Welding, Electric, Plumbing Transportation

Complete the section below if you are current employed:

Employer/Company:

Job Title/Position:

Wage:

Start Date:

Full or Part Time

Do you receive benefits? (401k, health insurance, dental, etc.)

Program Requirements, Goals, & Acceptance
Life Learning Center requires that you secure employment or enroll into post-secondary education in order to graduate from the Foundations for a Better Life program. Are you committed to meeting this requirement? *

I am committed to fulfilling the graduation requirements of obtaining employment or enrolling into post-secondary education I have questions or concerns and am not fully committed to fulfilling the graduation requirements of obtaining employment or enrolling into post-secondary education
Why do you want to be accepted into the Foundations for a Better Life program? *
What do you hope to accomplish if you are to be accepted into the Foundations for a Better Life program? *
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.
Phone Number

Area Code Phone Number
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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