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(C) HOUSING SITUATION What is your current housing situation? ☐ Rent ☐ Own ☐ Homeless/House to House ☐ In a shelter Are you receiving housing assistance? ☐ Yes ☐ No If yes, what type?

Is your housing situation safe and stable for you and your children? ☐ Yes ☐ No If no, describe:

(D) HEALTH Do you have health insurance? Yes ☐ No ☐ Do you have health concerns (emotional or physical) that would prevent you from seeking or keeping employment? ☐ Yes ☐ No ☐ I choose not to answer If yes, describe:

If you remember, what was the date of your last physical?

Do you have problems with any of the following? ☐ Walking ☐ Lifting ☐ Dental problems ☐ Back problems ☐ Standing or sitting for long periods ☐ Vision, speech, or hearing ☐ Tiring easily ☐ Breathing difficulty ☐ I choose not to answer Have you ever been hospitalized? Yes ☐ No ☐ I choose not to answer ☐ If yes, why?

Have you ever received counseling? ☐ Yes ☐ No ☐ I choose not to answer Are you currently receiving counseling? ☐ Yes ☐ No ☐ I choose not to answer If currently receiving counseling, why?

Are you taking any prescription medications? ☐ Yes ☐ No ☐ I choose not to answer If an employer gave you a drug test, could you pass? ☐ Yes ☐ No If no, could you pass given one month’s notice? ☐ Yes ☐ No

(E) EMPLOYMENT GOALS Do you have any job or career goals? Yes ☐ No ☐ If yes, then please explain?

If no, then how do you plan to support yourself and your family over the next 12 months? Do you have other goals you would like to accomplish in the next 12 months?

What actions will you need to take in the next 6-12 months that will help you reach your career goal?

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