Client Data Sheet

Client Data Sheet
Program*
Option*
Funder*
Location*
Start Date*

MonthDayYear
Date
Case Manager*
Have you attended a program at Goodwill Industries of Wayne & Homes Co in the past*
Client Full Name Include Middle Initial*
Maiden Name
Address*
City*
State*
Zip Code*
Phone Number*
Email- Enter none@none.com if they don't have one*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Race*

WhiteBlack or African AmericanAmerican Indian or EskimoAsian or Pacific IslanderMulti RaceHispanic/LatinoOther
Marital Status*

MarriedSingleDivorcedSeparatedWidowed
Conditions/Ancillary Services

Mental Health ProviderSTEPSSSI/SSDIFood StampsMedicare/MedicaidCash RecipientFederal Earned Income Tax CreditChildren ServicesEnergy Assistance
Notes
Conditions/Ancillary Services
Disability/Medical

Blindness/Visual ImpairmentDeafnessOther Physical DisabilityAutismNeurological DisabilityLearning Disability (other than Autism)Substance AbuseDevelopment Disability (other than Autism)Psychiatric/Emotional DisabilityPTSDOther Disabling ConditionPregnancyHas Mental Health CounselorHas General PractionerHas Eye DoctorHas Dentist
Notes
Disability/Medical
Living Arrangement*

HomelessMetroIndependentOne EightyGuardianResidential/Group Home
Education And Literacy*

Is able to read at a 5th grade levelIs able to do math at a 5th grade levelHas some computer knowledgeDropped Out/Not PursuingPursuing GEDGEDPursuing High School DiplomaHigh School DiplomaPursuing Associates DegreeHas Associates DegreePursuing Bachelors DegreeHas Bachelors DegreePursuing Masters DegreeHas Masters DegreePursuing Secondary CredentialHas Secondary Credential
Education Notes
(High SchoolDiploma Year, High School Name, Military (last rank and branch), Certificates/License(state), College Name (state, degree, and major)
Means of Transportation

FamilyMR/DDTransitSchoolWalksDrivesGoodwill TransportationTaxi Subsidized (taxi pass)Taxi Unsubsidized (no taxi pass)Other
Legal History

Felony RecordProbation/ParoleCredit IssuesSex Offender
Notes
Legal
Support Needs

Has mentors and/or natural support system
Notes
Support Needs
Self-Reported Barriers
Cultural Barriers
Language Barriers
Racial Barriers
Sexual Preference Barriers
Religious Barriers
Socioeconomic Barriers
Social Barriers
Gender Barriers
Other Barriers (things you need)

Driver's LicensePermitState IDAccess to TransportationCar InsuranceDay CareCar SeatsBirth Certificate (self)Birth Certificate (Children)Social Security CardGreen Card
Notes
Other Barriers (things you need)
Case Management Use Only
Occupational Skills (WFT Only)

JanitorialRetailClericalOffice ManagementProductionFood Service
Assessment (OOD Only)

JanitorialRetailClericalProductionCommunity
General Information
Physical Appearance and Hygiene
Communication Skills
Mental or Emotional Status
Let's take some time to talk about you and what you're good at, what you enjoy and where you might need some support. This is all about getting to know you better and finding out the best ways we can help you succeed.
Your Strengths: What do you feel that you're good at What skills abilities or personal qualities are you proud of
Your Interests: What hobbies or activities do you enjoy What kind of work excites you
Skills related to work: (Are you comfortable in customer service or a team environment? Are there areas like managing conflict or staying productive that you’d like to work on? Do you feel confident finding and applying for jobs? How are your time and money management skills related to work?)
Challenges: (Is there anything like health, safety, or other barriers that might make reaching your goals harder?)
Client Signature*

Clear
Date*

MonthDayYear
Date
Case Manager Signature*

Clear
Date*

MonthDayYear
Date
Method used to complete this form*
Should be Empty: