Social Service

What is your age?

18 - 54

55 - Up

What's your highest level of education?

GED/High School Diploma

Some College

Associates or Bachelors (circle one)

Are you working with any case manager/case managers?

Housing

Self Sufficiency

Crisis Center

Other (please specify)

Are you able to work and what types of income do you have? (check all that apply)

Work - Yes or No (circle one)

Employment

Unemployment

SS or SSI

Other (please state type of income) __________________________________________________

What is your employment status?

Full time

Part time

PRN

If unemployed, are you currently looking for work?

Yes

No

Other than disabled or 62 years of age or older, what is your reason for being unemployed?

Can't find employment

Lack of skills/education

Criminal Background (circle one) Misdemeanor Felony Probation Other

Lack of Transportation

Language barrier

Other (please explain) __________________________________________________________________________________

Would you be interested in (check all that apply):

Career Assessment

Career/Job Training

Help with Resume

Work Clothes

Counseling (please state type of counseling) _____________________________________________________

Parenting Classes

Self Esteem

Abuse (please state kind) ____________________________________________

Are you in need of childcare or childcare assistance?

Yes

No

Do not have a need for child care

Would you be interested in a savings account that match what you put in?

Yes

No