Goodwill Industries of Wayne and Holmes Counties, Inc.
Program
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Please Select
ABAWD
CCMEP TANF
Community
Juvenile Court
OOD
WFT
ISY WIOA
OSY WIOA
Funder
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Juvenile Court
OOD
United Way
Wayne County Dept JFS
Status
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Active
Volunteer
Start Date
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Month
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Day
Year
Date
Case Manager
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Social Security Number
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Location: Goodwill and if applicable school location
State ID/Driver's License number
Expiration Date
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Month
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Day
Year
Date
Have you attended a program at Goodwill Industries of Wayne and Holmes Counties in the past?
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Please Select
Yes
No
Client Name (include middle initial)
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Maiden Name
Address (Street, City, Zip Code)
Address
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Street Address
City
State / Province
Postal / Zip Code
Phone
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Date of Birth
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Month
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Day
Year
Date
Gender
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Female
Male
Other
Race (Select One)
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American Indian or Eskimo
Asian or Pacific Islander
Black
Hispanic/Latino
Other or Multiracial
Unknown
White
Marital Status
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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
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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
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Homeless
Metro
Independent
Guardian
Residential/Group Home
EWH/SA
High School Diploma Year
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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
High School Name
Diploma
Military (last rank and branch)
Certificates/Licenses (state)
College (state degree and major)
Special Skills
Education Notes
Means of Transportation
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Family
MR/DD
Transit
School
Other
Walks
Drives
Taxi (Subsidized)
Goodwill Transportation
Taxi (Unsubsidized)
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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
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General Information
Physical Appearance and Hygiene
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Communication and Social Skills
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Mental or Emotional Status
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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.
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Client Signature
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Case Manager Signature
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Date
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Month
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Day
Year
Date
Select the method that was used to complete form
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This form was completed in person with the client
This form was not completed in person with the client
Case Manager Name
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