Consumer Datasheet

Goodwill Industries of Wayne and Holmes Counties, Inc.
Program *
Funder *
Status *
Start Date *

Month Day Year
Date
Case Manager *
Social Security Number *
Location: Goodwill and if applicable school location
State ID/Driver's License number
Expiration Date

Month Day Year
Date
Have you attended a program at Goodwill Industries of Wayne and Holmes Counties in the past? *
Client Name (include middle initial) *
Maiden Name
Address (Street, City, Zip Code) *
Phone *
Date of Birth *

Month Day Year
Date
Gender *
Race (Select One) *

American Indian or Eskimo Asian or Pacific Islander Black Hispanic/Latino Other or Multiracial Unknown White
Marital Status *

Married Divorced Single Widowed
Conditions/Ancillary Services (services you are using and/or agencies you are connected with)

Mental Health Provider STEPS SSI/SSDI Food Stamps Medicaid/Medicare Cash Recipient Federal Earned Income Tax Credit Children's Services Energy Assistance
Other Services or Agencies you are connected with or if appropriate N/A
Disability/Medical

Blindness/Visual Impairment Deafness Other Physical Disability Neurological Disability Learning Disability (other than Autism) Autism Developmental Disability (other than Autism) Psychiatric/Emotional Disability Substance Abuse PTSD Other Disabling Condition Pregnancy Has General Practicioner Has Dentist Has Eye Doctor Has Mental Health Counselor
Other Disabilities/Notes
Living Arrangement *

Homeless Metro Independent Guardian Residential/Group Home EWH/SA
High School Diploma Year *

Is able to read at least at a 5th grade level Is able to do math at a 5th grade level Pursuing Associates Degree Pursuing Bachelor's Degree Has some computer knowledge Pursuing Master's Degree Pursuing GED Has Associates Degree Needs GED Has Bachelor's Degree Has GED Has Master's Degree Pursuing Secondary Credential Has Secondary Credential Pursuing High School Diploma Has High School Diploma
High School Diploma Year
Military (last rank and branch)
Certificates/Licenses (state)
College (state degree and major)
Special Skills
Means of Transportation *

Family MR/DD Transit School Other Walks Drives Taxi (Subsidized) Goodwill Transportation Taxi (Unsubsidized)
Legal History

Felony Record Probation/Parole Credit Issues Sex Offender
Notes
Support Needs

Has mentors and/or natural support system
Notes
Cultural Barriers
Language Barriers
Racial Barriers
Sexual Preference Barriers
Religious Barriers
Socioeconomic Barriers
Social Barriers
Gender Barriers
Other Barriers (things you need)

Driver's License Permit State ID Access to Transportation Car Insurance Day Care Car Seats Birth Certificate (self) Birth Certificate (children) Social Security Card Green Card
For Case Management Use
Occupational Skill (WFT Only)

Janitorial Retail Clerical Production Food Service
Assessment (OOD Only)

Janitorial Retail Clerical Production Community
General Information
Physical Appearance and Hygiene *
Communication and Social Skills *
Mental or Emotional Status *
Case Managers should note self reported strengths, abilities, preference, hobbies and interests in addition to any barriers (including knowledge of job seeking techniques, attendance, knowledge of job quality and quantity, work related time and money management skills, knowledge of work practices such as payroll deductions and union requirements, issues with anger or conflict management, lack of customer service skills, knowledge of work ethic and knowledge of general corporate cultures. Does this consumer have health, safety or other risks that will interfere with the fulfillment of goals or outcomes? If so please explain. *
Consumer Signature *

Clear
Case Manager Signature *

Clear
Date *

Month Day Year
Date
Select the method that was used to complete form *
Case Manager Name *
Should be Empty: