Begin At Home Questionnaire
Required to participate in the Goodwill Begin At Home program
Email address *
Clear selection
First Name *
Last Name *
Phone Number (Area Code First) *
Street Address *
Zip Code *
What department do you work in at Goodwill? *
How long have you worked for Goodwill? *
Are you currently receiving health benefits through Goodwill? *
Are you currently taking advantage of your 401K benefit? *
What computer skills do you believe you are skilled at? *
Do you have permanent housing? *
Which of the following applies to your housing situation? *
Do you own a vehicle that brings you to and from work? *
Which of the following applies to your transportation situation. *
Do you have enough food to eat? *
Which of the following applies to your food situation *
Do you have adequate childcare? *
Which of the following applies to your childcare situation *
Are you able to provide yourself with the necessary clothing for work? (Uniforms) *
Which of the following applies to your clothing situation *
Have you earned a high school diploma or equivalent? *
What is your highest level of achieved education so far? *
Do you have a bank account? *
What is your current financial situation? (check all that apply) *
Are mental health services important to you for either issues of diagnosed/undiagnosed mental health or substance abuse or addiction counseling? *
What mental health services could you benefit from? *
Do you need any legal aid services *
How could you benefit from legal services? *
Have you been diagnosed with a disability? *
What disability services have you used? *
IF you do not have healthcare coverage through Goodwill, do you have it through another source? *
What is your current healthcare situation? *
Do you have access to the following: (Check all that apply) *
Do you have a drivers license in good standing? *
If you do not have a drivers license, what is in your way? *
Are you affiliated with a tribe? If so, which one? *
Signature (type full name) *
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This form was created inside of Goodwill Career Pathways Institute. Report Abuse