S.T.A.R Program Intake Form

S.T.A.R Program Intake Form
Thank you for showing your interest in the S.T.A.R Program! Please complete this short intake form so we can learn a bit about you and why you want to participate. This form should be filled out by the young adult/participant of the program. Parents and guardians are encouraged to help if need be, though we are looking for the authentic responses from the young adults themselves. Thank you!

If you have any questions. please email our Community Services Intake Coordinator, Jana Stevenson, at intake@foothillsacademy.org
Participant Name*

First NameMiddle NameLast Name
Age:*
Birth Date*

MonthDayYear
Gender (Assigned at birth):*
Gender Identity: *
Participant E-mail*
example@example.com
Phone #:
What are your diagnoses? Check all that apply.*

ADHDLearning DisabilityAutism Spectrum Disorder (ASD)Developmental Coordination Disorder (DCD)Other
What do you hope to learn in this program? *
Have you ever, or do you currently, have a job?*

YesNo
Are there any industries you want to work in or careers you want to learn about?*
Are there any struggles you are facing as you transition to adulthood? (examples: social anxiety, managing your diagnosis, communicating with older adults, making phone calls, writing formal emails, finding a job, etc)*

The following are skills we believe will be useful to you in the S.T.A.R program. Please rate the importance of each skill as it refers to your development and transition to adulthood. *

	Not Important	Somewhat important	No opnion	Important	Extremely important
Renting your own place
How to do your taxes
How to apply to post secondary
Building a resume
How to do well in an interview
Your rights as an employee/worker
Proper nutrition
How to cook for yourself
Budgeting
Managing responsibilties

What do you like to do in your free time? *
Do you feel ready for adulthood?*

YesNoSomewhat
What can help you prepare for adulthood? *
The S.T.A.R program builds life skills (resumes, renting your own apartment, budgeting, etc.) and provides work experience through volunteering. Which is most important for you to learn?*

Life SkillsWork/Volunteer ExperienceBothOther
Is there anything you want to know about adulthood? *
Should be Empty: