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2. First Name*
3. Last Name*
5. Street Number*
6. Street Name*
7. Apt #
9. City*
10. State*
11. Zip*
13. Phone *
14. Email *
16. Employment
18. Are you currently employed?*
    -- Select One --Yes, part timeYes, full timeNo, unemployed
19. If yes, where?
21. When did you start working there?
22. Do you get any benefits from your employer? (check all that apply)

    1. Health Insurance
    2. Retirement Account
    3. Other
24. Do you have a disability that affects your ability to work?*

    1. Yes
    2. No
26. Education
28. What is the highest level of school you have completed?*

    1. 5th
    2. 6th
    3. 7th
    4. 8th

    1. 9th
    2. 10th
    3. 11th
    4. HSED - High School Equivalency Diploma

    1. 12th
    2. 13th
    3. 14th
    4. Associates Degree

    1. 15th
    2. 16th
    3. Bachelors Degree
    4. 16+
30. Are you currently enrolled somewhere to further your education?*

    (i.e. certificate programs, associate's degree program, bachelor's degree, apprenticeships, etc.)

    1. Yes
    2. No
31. If yes, where are you enrolled?
32. What are you studying?
33. Anticipated completion date
35. Resources Your Household Receives
37. Are you or any members of your household receiving: (check all that apply)*

    1. FIP or TANF
    2. Medicaid/Children's Health Insurance Program
    3. Food Stamps
    4. Earned Income Tax Credit
    5. No, one receives any of these resources
39. For Households with Children
41. How many children live in your assisted unit? (Please enter "0" if no children live in the assisted unit)*
42. 10. How many of your children receive childcare assistance from DHS? (Please enter "0" if no children live or receive child care assistance in the assisted unit) *
44. Needs/Wants
46. Are you interested in receiving more information on any of the following services? Please check all that apply.*

    1. HSED (formly GED)
    2. Job Training/Certification
    3. Post Secondary School/College
    4. Vocational Training/Vocation Rehab
    5. Job Search/Job Placement
    6. Homeownership Counseling

    1. Job Rentention
    2. Transportation
    3. Health Services (physical, emotional, spiritual)
    4. Alcohol or other Drug Abuse Prevention Serivecs
    5. Child Care
48. What goals have you worked on since the last time we met? *
50. Are there any goals you would like to add or revise? *
52. What activities have you participated in to increase your income? *
54. Please list any additional information you would like us to be aware of:*
56. Please type your name as an electronic signature: *
57. Date: *
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field