Client Data Sheet

Program

Option

Funder

Location

Start Date

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

Format: (000) 000-0000.

Email- Enter none@none.com if they don't have one

example@example.com

Date of Birth

Date

Gender

Race

Marital Status

Conditions/Ancillary Services

Notes

Conditions/Ancillary Services

Disability/Medical

Notes

Disability/Medical

Living Arrangement

Education And Literacy

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

Legal History

Notes

Legal

Support Needs

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)

Notes

Other Barriers (things you need)

Case Management Use Only

Occupational Skills (WFT Only)

Assessment (OOD Only)

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?)

What is your preferred work schedule?

Client Signature

Date

Case Manager Signature

Date

Method used to complete this form