Form Center

Individual Service Strategy

2. Name

3. Social Security Number

4. Date Plan Began
   Date Plan Began

6. Contact Number

7. Email Address

11. I. Education / Training

13. Did you complete high school or get a GED?

    1. Yes
    2. No

14. If not, what was the last grade you completed?

16. Have you received any post-high school education or training?

    1. Yes
    2. No

17. What training?

19. What school?

20. Did you complete?

    1. Yes
    2. No

22. What, if any, occupational license or skills certifications do you possess (ex: LPN, welding, nurse aide, cosmetology, etc.)?

24. Are you currently attending any school, training, or educational classes?

    1. Yes
    2. No

25. What training?

27. What school?

29. What, if any, training or education would you require to attain a career goal and self-sufficiency?

33. II. Skills / Experience

35. What job experience and / or occupational skills do you currently possess?

37. Do your skills/experience qualify you for employment at an adequate wage?

    1. Yes
    2. No

39. Do you have a disability or personal circumstance that will prevent you from returning to a previously held occupation?

    1. Yes
    2. No

41. If so, explain.

43. Do you have experience and skills that are not marketable in the current labor market?

    1. Yes
    2. No

45. If so, explain.

47. Do you possess good job search skills such as interviewing, completing applications, resume writing, etc.?

    1. Yes
    2. No

49. Please explain.

51. Have you encountered problems with supervisors/co-workers in the past?

    1. Yes
    2. No

53. Please explain.

55. Have personal problems unrelated to the job interfered with employment in the past?

    1. Yes
    2. No

57. Please explain.

59. Have you ever been fired?

    1. Yes
    2. No

60. If so, explain.

64. III. Employment History
    Please begin with current or most recent employer.

    Please begin with current or most recent employer.

66. Name of Company

67. City, State

69. Job Title

70. Dates (From - To)
    Dates (From - To) Start Date

    —

    Dates (From - To) End Date

72. Reason for Leaving

74. Duties

78. Name of Company

79. City, State

81. Job Title

82. Dates (From - To)
    Dates (From - To) Start Date

    —

    Dates (From - To) End Date

84. Reason for Leaving

86. Duties

90. Name of Company

91. City, State

93. Job Title

94. Dates (From - To)
    Dates (From - To) Start Date

    —

    Dates (From - To) End Date

96. Reason for Leaving

98. Duties

102. IV. Job Goals

104. What is your occupational goal?

105. What wage will you require to be self-sufficient?

107. Name three specific personal goals that you hope to achieve as a result of working.

109. Employment Challenges

     Check all that apply

     1. Child Care
     2. Transportation
     3. Housing
     4. Ex-Offender

     1. Lack of Experience
     2. Lack of References
     3. Lack of Skills
     4. Reading

     1. Language
     2. Poor English Skills
     3. Health/Physical Limitations
     4. Mental/Emotional

     1. Legal
     2. Financial
     3. Addictions (Drug, Alcohol, Gambling etc.)
     4. Other
111. If other, explain

115. V. Occupational Preference
     Check all that apply.

     Check all that apply.

117. I like working with data and information. This includes factual information, numbers, specifications, research or data based information, codes, measurements, etc.

     Examples of this type of job may include accountant, bookkeeper, credit reporter, purchaser, claim adjuster, economist, etc.

     1. Yes
     2. No
119. Comments

121. I like working with people. This includes working directly with people or helping people.

     Examples of this type of job may include social worker, teacher, nurse, policeman, waitress, receptionist, etc.

     1. Yes
     2. No
123. Comments

125. I like working with things. This includes working with machinery, office equipment, shovels, tools trucks, etc.

     Examples of this type of job may include construction trades, air conditioning and heating technicians, auto mechanics, auto body repairers, electricians, welders, truck drivers, computer repairers, machinists, general labors, etc.

     1. Yes
     2. No
129. VI. Supportive Service Needs Checklist
     Check any issues listed below for which you have a need at this time.

     Check any issues listed below for which you have a need at this time.

131. Health

     1. Get an eye exam/eye glasses
     2. See a doctor for myself
     3. See a doctor for my child
     4. Reduce my alcohol use
     5. Reduce my drug use
     6. Get my teeth fixed, go to a dentist
     7. Get personal grooming/hygiene items (makeup, toothpaste, soap, deodorant, etc.)
     8. Needs special adaptations for work skills, because of disability

132. Housing

     1. Pay past due utilities
     2. Pay rent
     3. Reduce housing costs
     4. Emergency/temporary housing

134. Case Manager Notes

135. Case Manager Notes

137. Legal

     1. Get protection from a violent person
     2. Take care of my legal problems

138. Family

     1. Learn how to control my anger
     2. Provide basic essentials for family (food, shelter, clothing)
     3. Needs child care for children
     4. Learn money management skills

140. Case Manager Notes

141. Case Manager Notes

143. Transportation

     (Need for reliable transportation)

     1. Obtain driver's license
     2. Get help with bus passes
145. Case Manager Notes

147. Please indicate any special concerns not addressed in the above list.

151. Completed by Career Center Staff Only

153. VII. Action Plan

155. Education / Training Goals

157. Employment / Career Goals

159. Support Services

161. Other Referrals

163. Workshops

164. Business Service Team

     1. Job Referral
     2. OJT

165. Assessments

     1. Skills Matching
     2. Career Explorer
     3. Career Informer
     4. Career Tips
     5. TABE
     6. SAGE
     7. WorkKeys
     8. Financial Services

167. Member's Signature

168. Date
     Date

170. Case Manager Signature

171. Date
     Date

173. R&P Case Manager Signature

174. Date
     Date

Leave This Blank:


175. Print Only

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