Consumer Data Sheet

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

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

MonthDayYear
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*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Gender*
American Indian or EskimoAsian or Pacific IslanderBlackHispanic/LatinoOther or MultiracialUnknownWhite
MarriedDivorcedSingleWidowed
Mental Health ProviderSTEPSSSI/SSDIFood StampsMedicaid/MedicareCash RecipientFederal Earned Income Tax CreditChildren's ServicesEnergy Assistance
Other Services or Agencies you are connected with or if appropriate N/A
Blindness/Visual ImpairmentDeafnessOther Physical DisabilityNeurological DisabilityLearning Disability (other than Autism)AutismDevelopmental Disability (other than Autism)Psychiatric/Emotional DisabilitySubstance AbusePTSDOther Disabling ConditionPregnancyHas General PracticionerHas DentistHas Eye DoctorHas Mental Health Counselor
Other Disabilities/Notes
HomelessMetroIndependentGuardianResidential/Group HomeEWH/SA
Is able to read at least at a 5th grade levelIs able to do math at a 5th grade levelPursuing Associates DegreePursuing Bachelor's DegreeHas some computer knowledgePursuing Master's DegreePursuing GEDHas Associates DegreeNeeds GEDHas Bachelor's DegreeHas GEDHas Master's DegreePursuing Secondary CredentialHas Secondary CredentialPursuing High School DiplomaHas High School Diploma
High School Diploma Year
Military (last rank and branch)
Certificates/Licenses (state)
College (state degree and major)
Special Skills
FamilyMR/DDTransitSchoolOtherWalksDrivesTaxi (Subsidized)Goodwill TransportationTaxi (Unsubsidized)
Felony RecordProbation/ParoleCredit IssuesSex Offender
Notes
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
Driver's LicensePermitState IDAccess to TransportationCar InsuranceDay CareCar SeatsBirth Certificate (self)Birth Certificate (children)Social Security CardGreen Card
For Case Management Use
JanitorialRetailClericalProductionFood Service
JanitorialRetailClericalProductionCommunity
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*

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