Personal Intake

Personal Intake

Please answer the questions to the best of your ability. If you need assistance completing this form, please let us know by texting our office at 209-565-0474.
I. PERSONAL INFORMATION
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In terms of ethnic, racial, nationality- how do you identify?
Do you speak a language other than English?
If you speak a language other than English, please list here:

Are you currently enrolled at Delta College?
Length of time in years or months you have been a CalWORKs participant
Please list any CalWORKs activities completed prior to assessment
Are you currently or have you been a client of the California Department of Rehabilitation?
Are you currently or have you ever received services or financial support through any of the following? Check all that apply.

Other
II. FAMILY HISTORY
Do you or anyone in your family have difficulty learning?
please describe
Do you or anyone in your family have any other type of disability (e.g. physical, emotional, vision or hearing)?
Describe any family issues you feel have affected you in learning or employment (e.g. parents separated, pregnancy, no child care, socio-economic factors).
What is your marital status
Who are you currently living with? (children, parents, extended family)
How many children do you have?
Age of child 1
Do you have any other children?
Age of child 2
Do you have any other children?
Age of child 3
Do you have any other children?
Age of child 4
Do you have any other children?
Age of child 5
Do you have any other children?
Age of child 6
Do you have any other children?
Age of child 7
Do you have any other children?
Age of child 8
Do you have any other children?
Age of child 9
Do all of the above children live with you?
If no, please explain:
III. EMPLOYMENT
Are you currently employed?
Where are you currently employed and what is your job title? for example: Amazon/Picker
Do you have any previous employment?
Where were you previously employed and what was your job title?
Do you have any previous employment?
Where were you previously employed and what was your job title?
Do you have any previous employment?
Where were you previously employed and what was your job title?
IV. HEALTH INFORMATION
Do you have any vision issues?
Please describe:
Do you wear glasses or contact lens?
Are you wearing them today?
Do you have any issues associated with your hearing?
Please describe:
Do you have allergies or Asthma?
Have your allergies, Asthma and any medications used for those two conditions impacted employment or your ability to learn?
Please describe how your Asthma or Allergies and any medications used for those two conditions have impacted your ability to learn.
Are you on any prescribed medications?
Please describe types of medication and reason for prescription:
Have you ever been on a long-term program of medication?
Please describe:
Have you ever had difficulties with attention, concentration of hyperact
Please describe:
Have you ever had a head injury?
Specify when and how the head injury occured:
Have you ever had seizures?
Pease describe and specify when:
Have you ever had a neurological exam (x-ray of brain or spine)?
What age and for what reason?
Have you ever had any serious injuries or illness (e.g. headaches, fever, carpal tunnel, job injury)?
Please specify when and describe its impact on your employment and or education:
Have you ever been hospitalized for emotional issues?
Specify when and for how long:
Are/or have you participated in individual or group counseling for emotional problems?
Please describe:
Do you have a history of substance abuse?
Please describe
V. EDUCATIONAL INFORMATION
As far as you can recall, have you ever had problems in school?
What grade or age were you?
If you had problems in school, what do you think the reasons were? Check all that apply
Did you attend more than two elementary schools in grades (K-6)?
Please explain:
Did you attend more than three schools in grades (7-12)?
Please explain:
Were you retained in school (e.g. held back, repeated a grade)?
What grade and why?
Have you ever received special education services or been in remedial classes?
If yes, check all that apply:

Other
VI. PREVIOUS EDUCATION
Did you receive your high school diploma?
Did you receive your G.E.D.?
High School Diploma completed where and what year?
G.E.D completed where and what year?
If you did not earn a high school diploma or G.E.D. what is the highest grade completed?
Do you have any of the following degree or certificates? Check only ones completed.
If so, name of training and major/program completed:
Are you currently attending school or a training program?
If so, name of school, major and degree working towards:
What year did you begin your training program?
Did you complete the program?
If training is in progress, when are you scheduled to complete?
Have you participated in any formal job training?
If yes, please list training attended and year attended.
List any certificates you received.
VII. CURRENT SKILLS

Computer knowledge: Please select the option that matches best.

Rows	None	Some	Good
Internet
E-mail
Spreadsheets
Database
Powerpoint
Word Processing

Typing/keyboard speed (words per minute)
Ten key speed (strokes per minute)

Tool experience: please select the option that matches best

Rows	None	Some	Good	Very Good
Hand tools
Power tools

VIII. TRANSPORTATION
Do you have a current California Driver's License?
If no, have you ever had a California Driver's License?
Do you currently have outstanding fines or child support payments preventing you from having a California Driver's License?
Please explain:
What type of transportation will you use to get to a job or training?
IX. LEGAL ISSUES
Do you have any legal issues on your record that may impact employment?
If yes, please describe: the year, type of conviction, whether it was a felony/misdemeanor, and whether you are on parole/probation:
X. RESUME
Do you have a current resume?
Do you need assistance in completing a resume or updating an existing one?
Should be Empty:

Rows	None	Some	Very Well
How well do you speak second language
How well do you you read in second language
How well do you write in second language

Personal Intake

I. PERSONAL INFORMATION

II. FAMILY HISTORY

III. EMPLOYMENT

IV. HEALTH INFORMATION

V. EDUCATIONAL INFORMATION

VI. PREVIOUS EDUCATION

VII. CURRENT SKILLS

VIII. TRANSPORTATION

IX. LEGAL ISSUES

X. RESUME