Language
English (US)
Spanish (Latin America)
Enrollment Survey
Eligibiliity, suitability and Congruence
Demographics
Name
*
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
Date
Date of birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Race
*
Please Select
Black
White
Asian
Pacific Islander
Native American
Hispanic
Hispanic (non-White)
LatinX
Gender
*
Please Select
Male
Female
Transgender
Last 4 of social security number
US citizen
*
Please Select
YES
NO
IN PROGRESS
WORK VISA
Relationship status
Please Select
Single
Dating
Married
Divorced
-County
*
Please Select
El paso-COS
Pueblo-PUE
Denver-DEN
Arapahoe-AUR
Adams-AUR
Jefferson-Den
Douglas-AUR
El paso CSC-WHealthy
Which county do you live in
Email
example@example.com
Initials(your initials)
*
Put your initials here at the minimum two letters
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Eligible
Eligible: Select ALL the boxes that apply to you
*
I am 18-24 years old
I am currently on parole
I am currently on probations
I am incarcerated
I am formerly incarcerated
I have a misdemeanor conviction
I have been arrested
I have been ticketed by the police department
I am 50(+) years old
I am unemployed
I am underemployed
I receive SNAP(food stamps)
I receive Medicaid/Medicare
I receive TANF
I want to volunteer
I want to do community service
I am in the halfway house
I am undocumented
A single parent
Student
Homeless/couch surfing
Lives in rural area
IEP
Intellectual delayed
Battled addiction alcohol
battled addiction to drugs
Work History(length of time you been employed throughout your lifetime)
*
None
0-1 years
2-5 years
6-10 years
11(+) years
Work Experience by industry
*
Entrepreneur
Services
Food industry
Construction
Transportation CDL
Hospitality
Real estate
Ware house
Manufacturing
IT/Coding
Automotive
Fitness
Beauty wellness
Human Services
Sales and Marketing
Lawn Care/Arborist
Retail
Green Energy
Customer service
Entertainment
None
Work intrest by industry
*
Entrepreneur
Services
Food industry
Construction
Transportation CDL
Hospitality
Real estate
Ware house
Manufacturing
IT/Coding
Automotive
Fitness
Beauty wellness
Human Services
Sales and Marketing
Lawn Care/Arborist
Manufacturing
Retail
Green Energy
Customer service
Entertainment
Trades(electrical, HVAC, plumbing, carpentry)
Barber
Do you want to work? Select all that apply to you
*
Full time
Part time
Temp
Not interested in working
Points to advance-Needs 4 pts
Suitability
Suitability(select all that apply)
*
I am willing to start work immediately
I am willing to learn new skills
I am willing to help others
I am willing to work on my sobriety
BESI
Suitability
I feel confident in my ability to communicate in a professional setting effectively
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I possess the necessary technical skills required for the job I am seeking
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I have access to reliable transportation to commute to work consistently
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I have a strong support system that encourages and supports my career goals
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I feel comfortable adapting to new technologies and software
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
IhavIe a stable and secure housing situation that allows me to focus on my employment
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I have access to affordable and reliable childcare services if needed
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I am confident in my ability to manage time effectively and meet deadlines
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I have received adequate training and education in my desired field
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
I feel confident in my ability to handle work related stress and challenges
*
Strongly disagree
Disagree
Neither agree or Disagree
Agree
Strongly Agree
Points to advance-needs 26
I use hard drugs(cocaine, meth, fentanyl, crack, Percocet etc.)
*
Please Select
Strongly agree(often/daily)
Agree(weekly3-5/week)
Somewhat agree(once-twice a week)
Socially(at events / with friends)
Disagree(very rarely )
Strongly disagree(never)
I drink Alcohol, spirits and/or Wine
*
Please Select
Strongly agree(often/daily)
Agree(weekly3-5/week)
Somewhat agree(once-twice a week)
Socially(at events / with friends)
Disagree(very rarely )
Strongly disagree(never)
Congruence
Additional barriers(select all that apply to you)
*
No license
Equipment tools
Job Leads
Physical Strength
Need License(CDL)
proper clothing/work attire
Criminal History
None
Sobriety
What are your top three values(what is important to you):
*
Enthusiasm
Ethics
adaptable
Dependable
Confident
Loyalty
optimistic
Integrity
Honesty
What are your Strengths(select all that apply)
*
Courageous
Hardworking
Organized
Bilingual
Reasoning
Creative
Communication
Math/Logic
Ambitious
Fast learner
Writing
Initiative
None
Background(select all that apply to you)
*
Grew up on Government system/assistance
Experienced Child abuse
Member of a gang
I am a single Parent
I grew up in a single parent household
Adopted
Victim of Domestic violence
I have been evicted before
Immigrant
Addicted to alcohol/drugs
Witnessed violence in household growing up
Facing eviction(currently)
I have Children
I had a child/children as a teenager
Have been fired from my job before
Immediate family addicted to alcohol/drugs(growing up)
Parents are immigrants
I was abused verbally as a child
I was suspended/expelled from school
I have been divorced
Traumatic brain injured
Goals short term choose five(5) goals
*
Stable housing
Enroll in GED
Enroll in college
Enroll in trade school
Get drivers license
Create a resume
Enroll in pre-apprenticeship/certificare Communityworks
Complete soft skill training
Complete a mock interview
acquire PPE
Acquire work appropriate clothing
acquire equipment for work
start a new job
Learn a new skill to get a promotion at work
Identify transportation for work
Get birth certificate
Get social security card
Acquire prescription eye glasses
open bank account to receive paycheck
Gym membership/ healthy
Get stable transportation
Long term goals (Choose five(5) goals)
*
Graduate college
Graduate highschool
Become a journeymen in the trades
Become a masters in the trades
Stay employed for three Consecutive months
Pass GED test
Get a raise
Become a supervisor
Become the manager
Get a better job/career
Change job/career
Stability life goals/reason for enrollment(choose five [5])
*
Save and buy a house
Get custody of kids
Get visitation to see kids
To support family
Get an apartment
Pay off fines
Pay off restitution
Pay child support
Get car fixed
Fix credit
Save and buy a car
sobriety/sober
get out of gang life
to add value to my community
Become independent
pay for legal fees
pay for medical bills personal
pay for medical bills family members/friend
Pay tuition(personal)
Pay tuition(family)
Pay off debt
Start a business
Retire
Get a gym membership
Get medical insurance
Congruence points-20 to be congruent
I agree to the release of informations(assessments[BPS, BESI, treatment plan, INSIT, ISP] my photos, videos and likeness as well as the accident waiver and release of liability in regards to working, volunteering, fitness/gym/working out community service with and or for Community Anchor Academy, WHealthy unlimited and associated programs and organizations.
*
Yes
No
I agree to the signing of w-9 and I-9 for potential employment with Community Anchor Academy, WHealthy, TAPP-in transitional subsidized employment and 3rd parties. I also agree fir Community Anchor Academy and WHealthy unlimited to contact my support system and employer for support and development purposes.
*
Yes
No
Signature-participant
*
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