Adult Pre-Intake

1
Full Name* This field is required.
First Name
Middle Name
Last Name
2
Your Birthdate* This field is required.
Date
Month
Day
Year
3
Please enter your Social Security Number* This field is required.
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email Address* This field is required.
example@example.com
6
How would you like us to follow up with you?Please select all that apply.
Email
Phone Call
Text
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Family Type* This field is required.
Single person, no children
One parent/guardian, with child(ren)
Two adults, no children
Two parents, with child(ren)
Other
9
Hispanic/Latino* This field is required.
YESNO
10
Race (select all that apply)* This field is required.
African
African American/Black
American Indian/Alaska Native
Asian/SE Asian/Pacific Islander
Hispanic/Chicano/Latino
Native Hawaiian
White
Multiracial
Other
11
Primary Language* This field is required.
12
Citizenship status* This field is required.
Citizen
Refugee
Immigrant
Asylum
13
Country of Origin
14
Do you identify as having a disability?* This field is required.
YESNO
15
Is this a barrier to employment?* This field is required.
YESNO
16
Receiving Public Assistance:* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
SSI
TANF/MFIP
Food Support
General Assistance
Refugee Assistance
SSI
YesNo
YesNo
YesNo
YesNo
YesNo
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17
Are you a Veteran of the U.S. armed forces* This field is required.
YESNO
18
Discharge Date* This field is required.
Date
Month
Day
Year
19
Served for less than 180 days* This field is required.
YESNO
20
Active or honorably discharged* This field is required.
YESNO
21
Spouse of a Veteran?* This field is required.
YESNO
22
Surviving spouse of a veteran?* This field is required.
YESNO
23
Is chemical dependency a concern?* This field is required.
YESNO
24
Convicted of a crime:* This field is required.
YESNO
25
Last grade or level of education completed:* This field is required.
26
Current school status:* This field is required.
Not in school, already graduated or earned GED
Not in school, no diploma/GED, currently age 17+
Not in school, no diploma/GED, currently under 17
In school, high school or less
In school, alternative school
In school, beyond high school
27
If In school, School name:* This field is required.
28
Current housing status:* This field is required.
Stably housed - Own
Stably housed - Rent
Temporary, transitional, or homeless
29
Monthly household income from all sources:* This field is required.(Include wages, spouse’s wages, cash assistance, and other income)
30
Number in household:* This field is required.Include only self, partner who lives with you (if any), and children who live with you (if any)
31
Currently employed:* This field is required.
YESNO
32
Last date of paid employment:* This field is required.
Date
Month
Day
Year
33
Currently Employed, enter information below* This field is required.
Current Job Title
Hourly Wage
Hours Per Week
34
What are your career or training goals?* This field is required.
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Large
Normal
Small
Ok
Ok
35
What type of work are you interested in?* This field is required.
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Small
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Ok
36
What are your strengths?* This field is required. (e.g., communication, teamwork, problem-solving, creativity, computer skills)
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Large
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Ok
Ok
37
What are your current challenges or barriers to employment?* This field is required. (e.g., lack of transportation, childcare, financial difficulties, lack of support network)
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Ok
38
What type of support would be most helpful to you?* This field is required.(e.g., job search assistance, career counseling, life skills training, financial literacy training)
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Ok
39
Unemployment Benefits:* This field is required.
I am Currently receiving unemployment benefits
I have used all my unemployment benefits
I haven't received unemployment
40
By typing my name below, I acknowledge that the information provided in this form is true and accurate to the best of my knowledge.* This field is required.
First Name
Last Name
41
Thank for completing out Pre-Intake questionnaire!

A Workforce Specialist will be in contact with you shortly.

At your first appointment you will need to bring:

Identification Card (ID, Drivers License, Passport)

Social Security Card

Current Resume if you have one

If you have any questions please feel free to reach out to the Workforce team or speak to someone at the front desk.

Thank you,

EMERGE Workforce Staff
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