Adult Program Intake Assessment

Easterseals Adult Program

Intake Assessment
I. Basic Identifying Information
Service*

Job ReadinessJob DevelopmentJob RetentionOccupational SkillsPWEAutre
Full name*

First NameLast Name
Last 4 of Social Security Number*
Example: 2456
Gender*

MaleFemaleN/AAutre
Date of Birth

MonthDayYear
Date
Ethnicity*

NativeAfrican AmericanWhiteHispanic or LatinoI'd rather not say.Autre
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail
Emergency contact*

First NameLast Name
Relationship*
Phone number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
example@example.com
Please list any pertinent medical/possible risks information below, if applicable:
Separate items with a comma
No potential risks identified such as: seizures, severe allergy, injuries, medical conditions
II. Benefits Received
Veteran Status

I am a US VeteranA member of my household is a US VeteranI am not a US Veteran and neither is anyone in my household
Benefits

SSSSIFood StampsTANMedicaidMedicarePublic HousingN/AAutre
III. Education Information
Highest Grade Level Completed
Select all that apply:

Certificate of AttendanceHigh School DiplomaGEDJPTA CertificateSome Trade SchoolGradTradeSome CollegeCollege Graduate - AssociatesCollege Graduate - BachelorsCollege Graduate - MastersCollege Graduate - Doctorate
If applicable, list any areas of study, certificates, majors, or diplomas:
Separate items with a comma
V. General Questionare
Legal Issues:

US CitizenPast Criminal HistoryCriminal Charges PendingProbationParoleWork PermitIndependentWard of the StateGuardianshipWages will be garnished
Work Documents and Transportation:

Social Security CardDriver's LicenseMAX TransitClassTranDrives personal vehicleAuto InsurancePocket Resume/Master ApplicationIn need of Pocket Resume/Master Application
Other services needed:

Occupational SkillsJob ReadinessJob DevelopmentAutre
VI. Narrative
List all, if any, suggestions, comments, or concerns:
Separate items with a comma
Should be Empty:

Easterseals Adult Program

I. Basic Identifying Information

II. Benefits Received

III. Education Information

V. General Questionare

VI. Narrative