Name:
When is the best time to call/contact you?
Highest level of school completed (check one):
(select an option)
Elementary/Middle School
Some High School
High School Graduate/GED
Some training after high school
Some College
College Graduate
Do you need/want a GED?
(select an option)
Yes
No
Are you currently in a school/training program?
(select an option)
Yes
No
If yes, where, what are you studying, how long have you been in, when will you complete?
If you have some other training after finishing high school, explain what and when. List any certificates or degrees earned.
If you have attended college, explain where and when. List any certificates or degrees earned.
Are you interested in attending any training or college course?
(select an option)
Yes
No
If yes, what would you like to study?
Do you know how to use a computer?
(select an option)
Yes
No
If no, are you interested in learning how?
(select an option)
Yes
No
Have you ever attended budgeting/credit classes?
(select an option)
Yes
No
Have you ever attended homeownership classes?
(select an option)
Yes
No
Are you currently working?
(select an option)
Yes
No
If yes, where are you employed?
When did you begin your employment here?
Type of Employment?
(select an option)
Full-Time
Part-Time
Permanent
Temporary
Seasonal
Is overtime available at this job?
(select an option)
Yes
No
What type of work do you do? (ex: factory, retail, receptionist, secretary, etc.)
What type of work have you done in the past?
Where was your last job?
Dates of last job
Reason for leaving last job
If you are currently working, are you looking for a new job?
(select an option)
Yes
No
What are you looking for that is not available at your current job?
If you could have ANY job you wanted, what would you choose?
Are you interested in Career Counseling?
(select an option)
Yes
No
Do you need help finding school choices, financial aid, etc.?
(select an option)
Yes
No
What do you feel are your strongest employment skills?
List all household members: (Name, Relationship, Date of Birth, Work/School Status)
Have you ever participated in ORHA's FSS program in the past?
(select an option)
Yes
No
If yes, how long ago?
(select an option)
less than 6 months
6 month-1 year
If yes, did you successfully graduate from the program?
(select an option)
Yes
No
Are you behind in your rent payments?
(select an option)
Yes
No
Have you had emergency rental help?
(select an option)
Yes
No
Do you have past due utility bills?
(select an option)
Yes
No
If yes, which utilities?
Do you have any shut-off notices?
(select an option)
Yes
No
Do you run out of food during the month?
(select an option)
Yes
No
If yes, how often does this happen?
(select an option)
some months
most months
every month
Do you use the food bank/soup kitchen?
(select an option)
Yes
No
If yes, how often do you need to use these?
(select an option)
some months
most months
every month
more than once a month
Do you use the WIC program through the Health Department?
(select an option)
Yes
No
Do you need clothes to attend school or work?
(select an option)
Yes
No
Who do you go to for help when you are having problems?
What types of assistance do they provide (ex: emotional support, money, transportation, emergency day-care services, etc.)
Do you have relatives, close friends, or neighbors that help you?
(select an option)
Yes
No
Do you receive help from social service agencies?
(select an option)
Yes
No
If yes, which ones?
Do you have anyone you can talk to about personal problems?
(select an option)
Yes
No
Do the people you talk to provide help and support?
(select an option)
Yes
No
Do you feel that you may need counseling?
(select an option)
Yes
No
Do you belong to any groups, clubs, churches, etc?
(select an option)
Yes
No
If so, what are they?
Do your children participate in school activities, clubs or programs?
(select an option)
Yes
No
If so, what are they?
Do you have health benefits or medical coverage for you or your family?
(select an option)
Yes
No
If yes, type of coverage:
Does it pay for medications?
(select an option)
Yes
No
Would you be interested in counseling of any type for you or anyone in your household?
(select an option)
Yes
No
Have you ever taken any nutrition classes?
(select an option)
Yes
No
Are you currently involved or expect to be involved in any court or legal matter? (Including child support and child custody hearings)
(select an option)
Yes
No
If yes, please explain:
Is anyone currently living with you involved in the juvenile or adult legal system?
(select an option)
Yes
No
Have you ever been convicted of a crime?
(select an option)
Yes
No
If yes, was this crime a felony?
(select an option)
Yes
No
Are you currently on probation or parole?
(select an option)
Yes
No
Do you have a driver's license?
(select an option)
Yes
No
If yes, is it valid?
(select an option)
Yes
No
Do you have a working car?
(select an option)
Yes
No
Do you have auto insurance?
(select an option)
Yes
No
Do you feel that you have reliable and affordable transportation available when you need it?
(select an option)
Yes
No
How do you get where you need to go?
Besides a car, what other types of transportation do you use?
Do you know how to access public transportation?
(select an option)
Yes
No
Has transportation prevented you from attending training/school or from maintaining emplyoment?
(select an option)
Yes
No
Do you currently have childcare services? (LEAVE THIS SECTION BLANK IF NOT APPLICABLE)
(select an option)
Yes
No
Do you receive payment assistance through a church, social service agency, or by other means?
(select an option)
Yes
No
What is your weekly cost for childcare?
Do you need after school care for your children?
(select an option)
Yes
No
Does their school offer this?
(select an option)
Yes
No
If you worked odd shifts, would you need childcare?
(select an option)
Yes
No
If you do not have childcare now, is there anyone in your house that would need care if you began a training program or found employment? List names and ages:
Have you ever taken parenting classes?
(select an option)
Yes
No
Are you interested in parenting classes?
(select an option)
Yes
No
How do you spend your free time?
How often do you meet with other people?
Do you have any hobbies, play sports, or belong to any clubs, churches, etc?
(select an option)
Yes
No
Do you use the library?
(select an option)
Yes
No
Do you have a library card?
(select an option)
Yes
No
Do you interact with people in your neighborhood?
(select an option)
Yes
No
If not, why?
What are some changes would you like to see in your life 3 months from now?
What are some changes would you like to see in your life a year from now?
What are some changes do you want to see in your life 5 years from now?
What are some strengths, skills, or characteristics do you have that will help you reach your goals?