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TEAMWORK ENGLEWOOD INTAKE FORM
Please fill out this form to the best of your knowledge. Questions with "*" next to them must be completed to submit this form. The TWE staff is collecting this information to improve our ability to connect you to the necessary resources. All information will be kept confidential.
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Name *
Do you have any of these things? *
Required
Home Address *
Chicago neighborhood *
Email Address
Phone number *
Who referred you to us?
What is your date of birth? (mm/dd/yyyy)
What is your gender?
Clear selection
What is your race?
How old are you?
Do you need cash assistance?
Clear selection
Do you need housing assistance?
Clear selection
Do you rent or own?
Clear selection
Do you need PPE (Personal Protective Equipment for COVID-19)?
Clear selection
Are you unemployed because of COVID-19?
Clear selection
Do you have internet access?
Clear selection
Do you have a computer?
Clear selection
Do you have a criminal background? *
Required
Are you currently on probation or parole?
Clear selection
Do you need legal assistance?
Do you have children in school? If so, what school(s) do they go to?
Do you take care of anyone other than children (grandchildren, foster children, family members)?
What is the highest education level you have attained?
Clear selection
If none, what was the last grade you completed, and what year was it?
What type of work are you seeking?
Do you have an updated resume?
Clear selection
Are you currently employed?
Clear selection
What was the last job you had? When was it? Why did you leave? (2 sentences maximum, please)
Have you taken a job readiness class? If so, where and when was it?
When was the last time you looked for a job?
Do you have a list of references?
Clear selection
How much do you / does your family make?
Clear selection
What hours/days can you work?
Have you missed work in the past? What was the reason?
Can you stand for long periods of time and lift objects weighing at least 20 pounds?
Clear selection
Have you ever worked for a non-profit?
Clear selection
Are you married?
Clear selection
What transportation is available to you?
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