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Car payment

Insurance

Healthcare

Childcare

Groceries

Other

Do you have income (include child support, TANF, SSI, etc.)? ☐ Yes ☐ No If yes, how much?

Would you like help enforcing or reviewing your child support obligation? ☐ Yes ☐ No Have you ever gotten your credit report? ☐ Yes ☐ No Do you have a bank account? ☐ Yes ☐ No If no, would you like to open an account? ☐ Yes ☐ No

(F) LEGAL AND/OR CRIMINAL HISTORY What legal documents do you need assistance obtaining (birth certificate, social security card, ID card, etc.)?

Have you ever been charged or convicted of a crime, including a DUI? ☐ Yes, misdemeanor ☐ Yes, felony ☐ No If yes, describe the charges and date(s):

If you were incarcerated, what were the dates from:

to Are you currently on probation? ☐ Yes ☐ No If yes, when will your probation end?

If convicted of a crime, has it kept you from getting a job? ☐ Yes ☐ No How do you explain this situation to employers?

Do you have any pending court cases ☐ Yes ☐ No If yes, explain:

(G) Section to be completed by Employment Services Program Staff Only Consent to Exchange Information Completed ☐ Yes ☐ No Referrals/Dates Referral: Referral Date: Referral: Referral Date:

(Optional) Additional Assessments Completed: Name of Assessment:

Name of Assessment:

Date of Completion:

Date of Completion:

Score/Outcome:

Score/Outcome:

032-22-1090-01-eng