Career and Independence Intake Form

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

MonthDayYear
Who is completing this form?

Myself (meaning the READY participant) with no assistanceMyself (meaning the READY participant) with some assistanceSomeone is completing this form on my behalf with my inputSomeone is completing this form on my behalf without my input
If someone is assisting or completing on your behalf, please add their name and reltaion to you
Example: Jenn Smith, mom
Name

First NameLast Name
Preferred Name
Age
Date of Birth

MonthDayYear
Gender

MaleFemaleOtherI do not knowI do not want to answer
How did you hear about CAYA?
What is your race and ethnicity? Please check all that apply.

American Indian or Alaska NativeAsianBlack or African AmericanHispanic/Latino or LatinaNative Hawaiian or Other Pacific IslanderWhiteOther race or ethnicityI do not knowI do not want to answerI prefer to describe myself:
I prefer to describe myself:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Permission to text?
Email
example@example.com
Is there anyone else who should receive communications about READY?
If you want a parent or someone else to receive communications about the program, please add their email here.
Communication Preference

TextEmailPhoneFace to Face
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where do you live?

City or suburbRural area like the countrysideType a questionI do not knowI do not want to answer
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 disabilityI have a developmental disabilityI 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

YesNo
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
The READY Program will be running several times throughout the year. Please indicate which month(s) you would prefer to start the program

JanuaryAprilSeptemberSummer Program
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?

YesNo
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 home100% work in the officeHybrid - Some from home, some in the officeUnsureInternshipVolunteer
Types of employment opportunities you are interested in

InternshipPart timeFull timeVolunteer
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 WritingMock interviewsSelf advocacyJob Search assistanceGoal planning and accountability partnerWorkplace etiquette, conflict resolution, andproblem-solving.Skill building at work: managing calendar, tasks, prioritizationCoaching
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.
Do you need financial assistance to cover the $400 tuition? Payments can be made in monthly installments.

Yes, please include me for financial assistance.No, I currently do not need assistance to pay the 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 ConditionsI Do Not Agree with the Above Waiver Conditions
Should be Empty:

Are You READY?

Personal Information

Getting To Know You Better!

Work History and Preferences

Goals

Waiver and Release of Liability