Stepping Stones to Success

Goal4 It!TM for CCMEP
Stepping Stones to Success
First and last Name
Youth Signature

Clear
TODAY'S DATE

MonthDayYear
Date
Primary Phone Number
Youth's Primary Email
example@example.com
If a Lead The Way staff person helped you with this application, what is their name?
If a Lead The Way staff person helped you with this application, what is their email address?
1.) What is your overall stress level right now? (FILL IN A CIRCLE)

I am VERY stressedI am moderately stressedI am in between stressed and not stressedI am not very stressedI am not stressed at all.
Where do you feel you currently are in these areas of life? (Fill in a circle in each Pathway row)
Housing:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Transportation:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Personal Well-Being:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Family Well Being:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Social Life:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Financial Health:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Legal History:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING, NO LEGAL ISSUES
Education/SKILLS Training:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, BUT COULD IMPROVETHRIVING
Career Path:

AREA OF SIGNIFICANT NEEDAREA OF NEEDSTABLE, ALMOST KNOW WHAT CAREER PATH I WANT TO TAKETHRIVING, I KNOW WHAT CAREER PATH I'M ON
3.) What do you hope to get out of this program?
4.) Do we need to update any of your information? (Example: address, phone number, email, employment, etc.)
5.) Prior work experience (includes military or volunteer experience)?

YesNo
If YES, please describe.
6.) What is your current level of education?
7.) Do you have transportation, child care, housing, clothing and other supports needed to enter your chosen career?

YesNo
If NO, what help do you need?
8.) What interests you?
9.) What skills or talent do you have?
10.) What are your strengths?
11.) What careers are you interested in?
Stepping Stones to Success - Release of Information

I give my approval for Ohio Job and Family Services (JFS) staff, OhioMeansJobs Center staff, and partner agencies to exchange and disclose necessary information about me for services to be provided to me by all programs administered via the JFS, OhioMeansJobs Center, and/or partner agencies. I attest that the information stated above is true and accurate, and I understand that the above information, if misrepresented, or incomplete, may be grounds for immediate termination of services and/or penalties as specified by law.
Youth Signature

Clear
TODAY'S DATE

MonthDayYear
Date
Parent Signature

Clear
TODAY'S DATE

MonthDayYear
Date
Goal4 It! for CCMEP

Note: As part of the new CCMEP program(s) in which you are participating, JFS is working with an independent evaluator (Ohio State University) to study the effectiveness of the program(s) and services being offered and to learn more about employment outcomes, including job placement. Ohio State University may contact you to gather information about your occupation, wages, working hours, and other feedback. The purpose of this contact will be to help JFS improve its program(s) and services. Your participation in the evaluation will be voluntary and any personal, identifying information about you that is obtained or shared by Ohio State University will be kept confidential.
Should be Empty:

Goal4 It!TM for CCMEP

Stepping Stones to Success

Where do you feel you currently are in these areas of life? (Fill in a circle in each Pathway row)

Stepping Stones to Success - Release of Information

Goal4 It! for CCMEP