Dream Cooperative Interest/Intake Form

Dream Cooperative Interest/Intake Form
The Dream Cooperative is a community based non-profit organization open to all individuals ages 10+, providing services targeted to ease the transition from adolescence to adulthood and promote well-being beyong into older adulthood. The Dream Cooperative hopes to serve as a community to individuals with disabilities and their families, where participants can engage in skill development for work readiness, educational outcomes, and independent living, as well as engage in leisure pursuits tailored to their own interests. Socialization and engagement in meaningful activity is at the core of the Dream Cooperative's approach to providing a neuro-diverse affirming and cultivating environment for the best outcomes of participants.
Demographic Information
Dreamer (Client) Full Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Client Age:
Legal Guardian Name (if applicable):

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Communication

Other
Diagnosis:
We value participation and accessibility! Please share any physical or environmental support you utilize:
If you selected "Other," type your response in the space below.
Please share any additional information, medical considerations, or behavioral supports that would help us provide a safe and supportive environment.
Pre-program Satisfaction & Interest Checklist
What makes you happiest?
Do you have any job skills at this time you would like to explore further?
If you could get paid to do something, what would you like to do?
Would you like to attend college but feel like there are barriers to pursuing that goal?
On a scale from 1-10 (1 = no need at all, 10 = critical need), how great is the need for a space like the Dream Cooperative (with services as described above) in the community for you or your loved one?

1

2

3

4

5

6

7

8

9

10

1 is No need at all, 10 is Critical Need
On a scale of 1-10, how knowledge able are you of community resources available for individuals with intellectual and developmental disabilities? (1= None, 10= Most)

1

2

3

4

5

6

7

8

9

10

1 is None, 10 is Most
Which service areas are you most interested in to reach your goals? (Select all that apply):
For each of the following areas (as described above in more detail), rate your percieved level of statisfaction with your engagement in the described area. Rating scale is 1-5 with 5 being the highest level of satisfaction.

Rating Scale:

1= Very dissatisfied

2= Dissatisfied

3= Neutral

4= Satisfied

5= Very Satisfied
Life & Independent Living Skills

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Work Readiness/Vocational Skills/Employment

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Socialization with peers

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Leisure exploration of areas of interest

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Arts

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Educational Supports

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Include any additional pertinent information that you feel we should know here, if applicable:
Would you like to be contacted to schedule an initial intake interview to become a Dreamer at the Dream Cooperative?
Should be Empty:

Dream Cooperative Interest/Intake Form

Demographic Information

Pre-program Satisfaction & Interest Checklist