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Individual Service Strategy
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Name
Social Security Number
Date Plan Began
Date Plan Began
Contact Number
Email Address
I. Education / Training
Did you complete high school or get a GED?
Yes
No
If not, what was the last grade you completed?
Have you received any post-high school education or training?
Yes
No
What training?
What school?
Did you complete?
Yes
No
What, if any, occupational license or skills certifications do you possess (ex: LPN, welding, nurse aide, cosmetology, etc.)?
Are you currently attending any school, training, or educational classes?
Yes
No
What training?
What school?
What, if any, training or education would you require to attain a career goal and self-sufficiency?
II. Skills / Experience
What job experience and / or occupational skills do you currently possess?
Do your skills/experience qualify you for employment at an adequate wage?
Yes
No
Do you have a disability or personal circumstance that will prevent you from returning to a previously held occupation?
Yes
No
If so, explain.
Do you have experience and skills that are not marketable in the current labor market?
Yes
No
If so, explain.
Do you possess good job search skills such as interviewing, completing applications, resume writing, etc.?
Yes
No
Please explain.
Have you encountered problems with supervisors/co-workers in the past?
Yes
No
Please explain.
Have personal problems unrelated to the job interfered with employment in the past?
Yes
No
Please explain.
Have you ever been fired?
Yes
No
If so, explain.
III. Employment History
Please begin with current or most recent employer.
Name of Company
City, State
Job Title
Dates (From - To)
Dates (From - To) Start Date
—
Dates (From - To) End Date
Reason for Leaving
Duties
Name of Company
City, State
Job Title
Dates (From - To)
Dates (From - To) Start Date
—
Dates (From - To) End Date
Reason for Leaving
Duties
Name of Company
City, State
Job Title
Dates (From - To)
Dates (From - To) Start Date
—
Dates (From - To) End Date
Reason for Leaving
Duties
IV. Job Goals
What is your occupational goal?
What wage will you require to be self-sufficient?
Name three specific personal goals that you hope to achieve as a result of working.
Employment Challenges
Check all that apply
Child Care
Transportation
Housing
Ex-Offender
Lack of Experience
Lack of References
Lack of Skills
Reading
Language
Poor English Skills
Health/Physical Limitations
Mental/Emotional
Legal
Financial
Addictions (Drug, Alcohol, Gambling etc.)
Other
If other, explain
V. Occupational Preference
Check all that apply.
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.
Yes
No
Comments
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.
Yes
No
Comments
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.
Yes
No
VI. Supportive Service Needs Checklist
Check any issues listed below for which you have a need at this time.
Health
Get an eye exam/eye glasses
See a doctor for myself
See a doctor for my child
Reduce my alcohol use
Reduce my drug use
Get my teeth fixed, go to a dentist
Get personal grooming/hygiene items (makeup, toothpaste, soap, deodorant, etc.)
Needs special adaptations for work skills, because of disability
Housing
Pay past due utilities
Pay rent
Reduce housing costs
Emergency/temporary housing
Case Manager Notes
Case Manager Notes
Legal
Get protection from a violent person
Take care of my legal problems
Family
Learn how to control my anger
Provide basic essentials for family (food, shelter, clothing)
Needs child care for children
Learn money management skills
Case Manager Notes
Case Manager Notes
Transportation
(Need for reliable transportation)
Obtain driver's license
Get help with bus passes
Case Manager Notes
Please indicate any special concerns not addressed in the above list.
Completed by Career Center Staff Only
VII. Action Plan
Education / Training Goals
Employment / Career Goals
Support Services
Other Referrals
Workshops
Business Service Team
Job Referral
OJT
Assessments
Skills Matching
Career Explorer
Career Informer
Career Tips
TABE
SAGE
WorkKeys
Financial Services
Member's Signature
Date
Date
Case Manager Signature
Date
Date
R&P Case Manager Signature
Date
Date
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