Date of Birth:

Intake Form

Personal Details:

Intake Date: Fiscal Year: SSN:

Last Name: First Name: Middle Initial:

I

L.I ________ __. Age: US Citizen:

Marital Status: € Single

€ Married

€ Divorced

€ Widowed

€ Other

Suffix:

I Address Information:

Addressl: ._I _________ _.

State:

Active Address: D

I Phone Details:

J.., _______ _. ... I _________ __ L.I _______ _.

Gender: € Male

€ Female

D

Other ID {passport#, visa

info, Etc.:

I .., ________ _.

Address2: ... I ________ __. City:

Zip Code: ._I _____ _.

Address Parish:

Phone Type: € Home

€ Business

Address Type: € Home

€ Business

€ Mailing

Active Phone: D Primary

Phone Number: 1 _

..._ _________ __. € Mobile

Alternate

Phone

Number 1:

Alternate

Phone

Number 2: 1 ..._ _________ _

Phone Type:

Phone Type:

1

€ Other

€ Home Active Phone: D € Business

€ Mobile

€ Other

€ Home Active Phone: D

€ Business

€ Mobile

€ Other

[Emergency Contact:]

Last Name: .. I _________ _. First Name: Relationship: € Father

€ Mother

Phone Number 1: Phone Number € Spouse

I

Friend

Legal Guardian

Other

Email:

Email Address: .. I _____________ _

I

Email Address

Type: Personal

Business

Other

Active Email:

Ethnicity Details:

Is Student Hispanic/Latino: ~

~

I

Check all that are applicable: American Indian or Alaska

Native

Asian

Black or African American

White

Native Hawaiian or Other

Pacific Islander

Program Details: I €

Primary

Program:

Adult Basic Education

Accelerating Opportunity (inactive)

€ Family Literacy

€ Workplace Literacy

Correctional Education Program

(inactive)

€ EL Program (ESL)

EL Civics (inactive)

€ Adult Secondary Education

€ Program for the Homeless

€ Community Corrections Program

€ Other Institutional Programs

€ Distance Education

€ Community Education

€ LA Career Pathway

€ Integrated English Literacy & Civics

Education

€ Integrated Education and Training

Program (IET)

€ Corrections 225

€

€

€

€ €

€

□

€

€

Pathway

Programs:

€

€

€

€

€ €

€

Business

Culinary/ Hospitality

Health Science

Information Technology

Manufacturing

Skilled Craft

Transportation

Other (Specify below)

Other:

Keyword:

{Flags): I

€

€

€

€

--I

ESL Student: □ I I Native Language:

Country of Highest

Education and/or

prior to entering

Adult Ed

I 2

I

I Past Enrollment in Adult Education

Have you ever been enrolled in an Adult Education Program before? □ If so, where? ).., _________________ ___.

I Enrollment Details

Current Employment Status:

Employed

Employed but re­

ceived notice of

Termination or

Military Separation

Pending

Unemployed

Not in the Labor

Force

Employer: Date of Employment: Occupation:

€

€

___ ____.I __ I __ I __ I --

€

Long Term Unemployed. > 27

Consecutive weeks.:

D Single Parent: D

€ Public Assistance: D Rural Area: Displaced Homemaker:

Dislocated Worker: D

D D

Cultural Barriers Hindering

Employment: Migrant and Seasonal Farm­

worker Status:

€ No

€ Seasonal Farm-

worker

€ Migrant and Sea-

sonal Farmworker

€ A dependent of a

seasonal, or mig-

tant and seasonal

farmworker

In Foster Care Aged Out of Foster Care

Exhausting TANF within 2 years (Part A Title IV of the Social

Security Act.

Individual with

disability:

D

D

□

D

□ € Yes

€ No

€ Not Disclosed

€

Job Corps: Yes

No

Unknown

Low Income: Youth Build: Yes

€ No

€ Unknown

€

€ €

Low levels of Literacy:

Check the box if any of the following conditions apply :

□ D (A) Receives, or in the 6 months prior to application to this program has received, or is a member

of a family that is receiving or in the prior 6 months prior to application to this program has re­

ceived:

D (i) SNAP or Louisiana Purchase Card Assistance (ii) TANF Assistance (iii) SSI Assistance or

D (iv) State or local income-based assistance i.e. Louisiana Medicaid, Section 8 Housing, Kinship

Care, Child Care Assistance, LSU Hospital Free Care, or Free Dental Program): or

3

□

Check the box if any of the following conditions apply :

D (B) Is in a family with total family income that does not exceed the higher of the poverty line or

70% of the lower living standard income level

D (C) Is a youth who receives, or is eligible to received a free or reduced price lunch under the Rich­

ard B. Russell National School Lunch Act (USC 1751 et seq);

D (D) Is a foster child on behalf of whom State or local government payments are made

D (E} Is an individual with a disability whose own income in the poverty line but who is a member of

a family whose income does not meet this requirement;

D (F) Is a homeless individual or a homeless child or youth or runaway youth

D (G} Is a youth living in a high poverty area.

Ex Offender Status: Tick the checkbox if any of the following conitions are true: Are you are per

son who either

D (A) has been subject to any stage of the criminal justice process for committing a status offense or

delinquent act?

D (B) Requires assistance in overcoming artificial barriers to employment resulting from a record of ar-

rest or conviction for committing delinquent acts, such as crimes against persons, against property,

Homeless Individual, Homeless Children and Youths, or Runaway Youth check if :

D (A} Lacks a fixed, regular, and adequate nighttime residence: this includes an individual who:

(i} is sharing the housing of other persons due to loss of housing, economic hardship, or a similar

reason.

(ii) is living in a motel, hotel, trailer park, or campground due to a lack of alternative adequate

accommodation.

(iii) is living in an emergency or transitional shelter

(iv) is abandoned in a hospital; or

(v) is awaiting foster care placement

D (B) Has a primary nighttime residence that is a public or private place not designed for or ordinarily

used as a regular sleeping accommodation for human beings, such as a car, park, abandoned build­

ing, bus or train station, airport or camping ground;

D (c) is a migratory child who in the preceding 36 months was required to move from one school dis­

trict to another due to changes in the parent's or parent's spouse's seasonal employment in agri­

culture, dairy, or fishing work; or

D (D) is under 18 years of age and absents himself or herself from home or place of legal residence

without the permission of his or her family ( i.e. runaway youth)

4

Adult: Have you received employment or training services through the One•Stop?

D No D Yes, local formula D Yes, statewide D Yes, Both local and statewide

Youth: Have you received employment or training services through the One-Stop?

D No D Yes, local formula D Yes, statewide D Yes, Both local and statewide

Vocational Rehabilitation: Have you received Vocational and Rehabilitation services?

D No D Vocational Rehabilitation D Voe Rehab and Employment, Statewide

D Both, Voe Rehab and Voe Rehab and Employment

Wegner-Peyser Act: Have you received technical training assistance from the one-stop?

0 Yes

School Status at Participation:

□

□

□

□

□ □

{1) Participant has not received a high school diploma or its recognized equivalent and is attending

any secondary school (including elementary, intermediate, junior high school, whether full or part­

time or is between school terms and intends to return to school.

(2) Participant has not received a high school diploma or its recognized equivalent and is attending

an alternative high school or an alternative course of study approved by the local educational

agency whether full or part-time, or is between school terms and is enrolled to return to school.

(3) Participant has received a high school diploma or its recognized equivalent and is attending a

post-secondary school or program (whether full or part-time), or is between school terms and is

enrolled to return to school.

(4) Participant is not within the age of compulsory school attendance; and is no longer attending

any school and has not received a high school diploma or its recognized equivalent

(5) Participant is not attending any school and has either graduated from high school or has

attained a high school equivalency

(6) Participant is within the age of compulsory school attendance, but has not attended school for

at least the most recent complete school year calendar quarter and has not received a high school

diploma or its recognized equivalent.

s

Received Training: Yes No Eligible Training Provider-Name

Type of Training Service

Eligible Training Provider-Program of Study I I Eligible Training Provider

CIP Code 1

____________ __,J

..__ _________ ____J

I Disability Details

Disability: € ADHD

€ Autism

€ Deaf Blindness

€ Deafness

€ Emotional Disturbance

€ Had an IEP in K-12

€ Hard of Hearing

€ Intellectual Disability

€ Multiple Disabilities

€ Orthopedic impairment

€ Other Health Impairment

€ Specific learning disabilities

€ Speech or Language Impairment

€ Traumatic Brain Injury

€ Visual Impairment

€ Other (Specify Below)

learning

Disabled:

Dyscalculia

Dysgraphia

Dyslexia

Related to Neurological Impairments

Other (Specify Below)

Other:

Other:

I Educational Details: I Highest degree or level

completed:

€ No formal school

€ Completed 1 Year

€ Completed 2 Years

€ Completed 3 Years

€ Completed 4 Years

€ Completed 5 Years

€ Completed 6 Years

€ Completed 7 Years

€ Completed 8 Years

€ Completed 9 Years

€ Completed 10 Years

6

€ €

€

€

€

I

Location: € US Based

€ Non-US Based

€ Completed 12 Years (HS Diploma not earned)

€ Completed 12 Years (HS Diploma earned)

€ Completed 13 Years

€ Completed 14 Years/Assoc Deg/Technical Diploma

€ Completed 15 Years

€ Completed Bachelor Degree

€ Completed Beyond Bachelor Degree

€ High School Equivalency Earned

€ Certificate of Attendance or Completion (HS Only)

€ Post Secondary Degree/Certificate Earned

I

I Goal: I € Improve Basic Literacy Skill

€ Improve English Language Skills

€ Obtain Citizenship Skills

€ Other Personal Goals

I Referrals:

Referral Date:

Referral To (WorkReadyU Program):

€ Avoyelles Parish School System

€ Avoyelles Parish Sheriff's Office

€ Baton Rouge Community College

€ Bossier Parish Community College

€ Catahoula Parish School System

€ Catholic Charities- Archdioceses of N.O.

€ Central Louisiana Technical Community College

€ Delgado Community College

€ East Baton Rouge Parish School Syst em

€ Fletcher Technical Community College

€ Hope House

€ Iberville Parish School System

€ Jefferson Parish School System

€ LCTCS

€ literacy Council of SW LA

€ Livingston Parish School System

I

€ Louisiana Delta Community College

€ Louisiana Department of Public Safety and Corrections

€ Northshore Technical Community College

€ Nort hw est Louisiana Technical College

€ Progressive Education Program, Inc (PEPI)

€ River Parishes Community College

€ Sabine Parish School System

€ South Louisiana Community College

€ St. Bernard Parish School System

€ St. Charles Parish School System

€ Terrebonne Parish School System

€ Volunteer Instructors Teaching Adults (VITA)

€ Winn Parish School System

€ YMCA of Greater N.O.

€ Youth Empowerment Project - NOPLAY

7

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