CPS Prescreen Form
Date
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Month
-
Day
Year
Date
Name
First Name
Last Name
County to work in
Does the applicant have all of the following requirements:
Is able to attest that they have a mental health diagnosis and have reacheda place in their recovery pathway where they can positively support others in asimilar situation
Eighteen (18) years of age or older
Have a high school diploma or General Equivalency Diploma (GED) (preferred).
Has maintained 6 months of consecutive employment or volunteer work experience; OR within the last three (3) years, has maintained at least 12 months of successful full or part-time paid or volunteer work experience.
Have you ever been convicted of a crime(felony or misdemeanor)? (A conviction does not automatically bar you from employment.) Please write in yes or no. If yes, please provide details.
Would applicant eventually like:
Full time
Part time
Does applicant have reliable transportation:
Yes
No
Prescreening done by:
Submit
Should be Empty: