Career and Independence Intake Form
Thank you for partnering with Caya on your journey of gainful employment and independence! Our approach leads with empathy and understanding and are committed to building your confidence and self-advocacy skills. We are so excited to work with you - thank you for trusting us!
Personal Information
Today's Date
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Month
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Day
Year
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Revision Date
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Month
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Name
First Name
Last Name
Preferred Name
Age
Date of Birth
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Month
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Day
Year
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Gender
Male
Female
Phone Number
Please enter a valid phone number.
Permission to text?
Please Select
Yes
No
Email
example@example.com
Communication Preference
Text
Email
Phone
Face to Face
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Single
Married
Divorced
Widowed
Do you identify as being neurodivergent? Some examples include: Autism spectrum disorder, ADHD, epilepsy
Yes
No
Highest Level of Education
Degrees or Certifications Obtained
Who lives at home with you
Getting To Know You Better!
The below questions help us learn more about the different parts of your life. This includes people, things, and understanding what is important to you.
Do you have transportation to/from work
Yes
No
Sometimes
How do you plan to get to/from work?
Do you need assistance with preparing lunch/snacks for the day if you were to go into the office?
What are your skills and strengths?
analyzing data, completing routine tasks, programming
What are some things that are challenging for you?
prioritizing work, staying on task, staying focused
Who is in your support system?
What makes you happy and motivate you?
What are the things that upset you?
Is there anything else you would like to share that would help in your career coaching journey?
Work History and Preferences
Have you been employed previously?
Yes
No
If yes, what jobs have you held previously?
What did you like about your previous jobs?
What did you NOT like about your previous jobs?
What is the perfect job for you and why?
Ideal work environment
100% work from home
100% work in the office
Hybrid
Unsure
Types of employment opportunities you are interested in
Internship
Part time
Full time
What do you think is the biggest barrier to you finding a job?
Have you ever completed any vocational training? If so, in what and when?
Goals
What are your professional goals?
What are your personal goals?
What areas are of interest to you
Resume Writing
Mock interviews
Self advocacy
Job Search assistance
Goal planning and accountability partner
Workplace etiquette, conflict resolution, andproblem-solving.
Skill building at work: managing calendar, tasks, prioritization
Coaching
You would say working with Caya is a success if you complete what?
For example: If I have an updated resume to apply to jobs I would be happy working with Caya.
Waiver and Release of Liability
In consideration of being permitted to participate in the programs, activities, and events of Come As You Are Inc., I, the undersigned participant, or the parent or legal guardian of the participant, hereby agree to the following: Assumption of Risk: I understand that participating in Come As You Are Inc.’s programs, activities, and events may involve inherent risks, including, but not limited to, physical exertion, interaction with other participants, and exposure to various environments. I voluntarily assume all risks associated with my participation. Release of Liability: I, for myself, my heirs, executors, administrators, and assigns, hereby release, waive, discharge, and hold harmless Come As You Are Inc., its directors, officers, employees, volunteers, agents, and affiliates from any and all claims, demands, liabilities, damages, injuries, actions, or causes of action arising out of or in connection with my participation in Come As You Are Inc.’s programs, activities, or events, including any claims arising out of negligence. Photographic Release: I grant Come As You Are Inc. the right to take photographs and videos of me during the programs, activities, and events. I agree that Come As You Are Inc. may use such images for promotional, educational, and other purposes without compensation to me. Behavior and Conduct: I agree to follow all rules, guidelines, and instructions provided by Come As You Are Inc. staff and volunteers. I understand that failure to adhere to these rules may result in my removal from the program, activity, or event without refund. Confidentiality: I understand that certain information disclosed during my participation in Come As You Are Inc.’s programs, activities, or events may be confidential. I agree to maintain the confidentiality of such information and not disclose it to third parties without the prior written consent of Come As You Are Inc. Indemnification: I agree to indemnify and hold harmless Come As You Are Inc., its directors, officers, employees, volunteers, agents, and affiliates from any and all claims, demands, liabilities, damages, injuries, actions, or causes of action arising out of or in connection with my conduct or actions during my participation in Come As You Are Inc.’s programs, activities, or events.
I Agree with the Above Waiver Conditions
I Do Not Agree with the Above Waiver Conditions
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