Basic Information
Name
First Name
Middle Name
Last Name
Suffix
Birth Date
-
Month
-
Day
Year
Date
SS#
*
Primary Language
*
Gender
*
Please Select
Male
Female
Transgender
Other
Decline to State
Hispanic?
Please Select
Yes
No
US Citizen
*
Please Select
Yes
No
Race
*
Please Select
American Indian / Alaska Native
Asian / Native Hawaiian / Other Pacific Islander
Black or African American
Caucasian or White
Other Race or Origin
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Email
example@example.com
State ID / License #
Issuing State
Expiration Date
-
Month
-
Day
Year
Date
How did you hear about Goodwill?
Vocational Rehabilitation Agency (DRS/TWC)
Workforce Innovation and Opportunity Act (WIOA) programs and services
Elementary / Middle / High Schools
Postsecondary schools/Community College systems
State Agency for the Blind (DBS)
Veteran Affairs or veteran services organizations
Department of Defense or military service organizations
Walk-in/self-referral
Social Security Administration (Ticket to Work)
Mental illness or developmental disability agency
Juvenile Justice System
Adult corrections or justice system
Temporary Assistance for Needy Families (TANF) Administration/Provincial Welfare Administration
Homeless shelters
Other public health, human or social service agencies or faith-based organizations
Supplemental Nutrition Assistance Program (SNAP)
Employer
What is your primary mode of Transportation?
Car / Truck
Public Transportation / Metro
Bicycle
Walking
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Contact Information
Please give us contact information for at least one person that will always know how to find you.
Contact 1:
Name
First Name
Middle Name
Last Name
Suffix
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Contact 2:
Name
First Name
Middle Name
Last Name
Suffix
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
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Employment and Education
Are you currently employed?
Yes
No
Are you looking for work?
Yes
No
What was your last date you were employed (if currently employed, use today’s date)?
-
Month
-
Day
Year
Date
What is your highest grade/level of education completed?
No formal schooling completed
Completed 8th grade
Less than high school diploma
GED/high school equivalency
Postsecondary non-degree award
Associate’s degree
Bachelor’s degree
Graduate degree
Do you have a vocational training or apprenticeship certificate?
Yes
No
Are you currently enrolled in the following:
High school diploma
GED/high school equivalency
Postsecondary non-degree award
Associate’s degree
Bachelor’s degree
Graduate degree
Not Applicable/Non enrolled in school or training
Have you completed any other training? (job readiness, financial wellness, soft skills, etc.)
If YES, please describe
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Military Veteran Experience
Did you serve at least one day of active duty in the U.S. military?
Yes
No
Service Start Date
-
Month
-
Day
Year
Date
Service End Date
-
Month
-
Day
Year
Date
Did you serve in a war zone?
None
Vietnam
Gulf I
OEF
OIF
Other
What was your discharge Status?
In what branch of the military did you serve?
Do you have a service-connected disability?
Yes
No
Are you a military spouse?
No
Yes
Are you the child, parent, sampling or other close relative of a military service member or veteran?
Yes
No
Are you a caregiver of an individual with a history of military service?
Yes
No
Were you referred to Goodwill from a Stand Down event?
Yes
No
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Household Information
Where do you currently live?
Owned/rented house or apartment in your name
With friends/family in a house or apartment in their name
In a shelter or transitional living facility
In a place not meant for habitation (car, vacant property, on the street)
Are you at risk of losing your living place soon?
Yes
No
How many adults live in your household?
How many children live in your household?
Have you been continuously homeless for the last year?
Yes
No
Have you been homeless four or more times in the last three years?
Yes
No
What is your annual household income (including everyone who lives with you)?
What is your relationship status?
Married
Unmarried partner
Single/Separated
Divorced
Married and living with spouse (currently you have married, listed, but please break it up)
Married and not living with spouse (currently you have married, listed, but please break it up)
Common law
Widows
Separated (currently listed with single – please separate it)
Other
Do you have custody of minor children (under 18)?
Yes
No
Are you or anyone in your household a person with AIDS or HIV+?
Yes
No
Are you a TWC (formerly DARS) Vocational Rehabilitative Services customer?
Yes
No
Do you receive SSI/SSDI and are eligible for “Ticket to Work”?
Yes
No
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Please check all that apply
If an asterisk is listed, please provide an explanation in the "Please List Details" box below.
Addiction *
Homelessness
Older worker (55+)
Lack of Transportation
Underemployed
Unemployed
Developmental Disability *
Learning Disability *
Offender - Incarcerated *
Offender - Released in last 6 months *
Offender - Released more than 6 months ago *
Victim of Domestic Violence *
HIV+/Aids (you or any household member) *
Teen Parent
School Dropout
In Foster System
In a Gang / At Risk Youth *
Blindness or other Visual Impairment
Deafness or Hard of Hearing
Other Physical Disability *
Neurological Disability
Learning Disability other than Autism (currently Learning Disability is listed, so just need to add the other than Autism descriptor)
Developmental Disability other than Autism (currently Developmental Disability is listed, so just need to add the other than Autism descriptor)
Criminal Background
History of Substance Abuse
Autism Spectrum Disorder
Psychiatric Disability *
Emotional Disability
Other Disabling Condition
Two or More Disabilities
Addiction is currently listed – please break them out into three categories (Addiction: Alcohol, Addiction: Drugs, Addiction: Other*
Dislocated Worker
Incumbent Worker
Underemployed, including working poor (currently Underemployed is listed, so just expanding it to include including working poor descriptor)
Immigrant
Refugee
Lack of Childcare Services
Lack of Market-Valued Postsecondary Credential
Lesbian, Gay, Bisexual, Transgender (LGBT)
Single Parent
*Please List Details
What location is this intake form being submitted from?
*
Please Select
1140 - GTS
River Oaks
Heights
Meyerland
Galveston
Cypress Station
Signature
Submit
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