Are You READY?
Please complete this intake form and we will reach out about your participation in an upcoming workshop. Thank you and we are SO excited to work with you.
Personal Information
Today's Date
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Month
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Day
Year
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Name
First Name
Last Name
Preferred Name
Age
Date of Birth
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Month
-
Day
Year
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Gender
Male
Female
Other
I do not know
I do not want to answer
I prefer to describe myself as:
I prefer to describe myself as:
What is your race and ethnicity? Please check all that apply. pe a question
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino or Latina
Native Hawaiian or Other Pacific Islander
White
Other race or ethnicity
I do not know
I do not want to answer
I prefer to describe myself:
I prefer to describe myself:
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
Where do you live?
City or suburb
Rural area like the countryside
I do not know
I do not want to answer
Marital Status
Single
Married
Divorced
Widowed
Which of the follow describes you? Check all that apply. A developmental disability (DD) starts before the age of 22. People with DD often need supports and services for life. Examples include: Down Syndrome, autism, cerebral palsy, hearing loss of deafness, and vision impairment.
I do not have a disability
I have a developmental disability
I have a disability that is not a developmental disability (e.g, learning disability)
I do not want to answer
Do you identify as being neurodivergent? Some examples include: Autism spectrum disorder, ADD/ADHD, dyslexia, social anxiety, OCD, epilepsy
Yes
No
Highest Level of Education
Degrees or Certifications Obtained
Who lives at home with you
How will you get to/from work and the READY program
Please Select
I plan to drive myself
Family will drive me
I will use Uber/Lyft
Public transportation
I do not have transportation
The READY Program will be running several times throughout the year. Please indicate which month(s) you would prefer to start the program
January
September
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 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 motivates 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 - Some from home, some in the office
Unsure
Internship
Volunteer
Types of employment opportunities you are interested in
Internship
Part time
Full time
Volunteer
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.
We hope to provide scholarships to individuals so everyone can experience the READY program. Please indicate below if you are interested in financial assistance opportunities.
Yes, please include me for financial assistance.
No, I currently do not need assistance to pay the $400 READY program fees
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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