Adult Services/Job Coach Services Getting to Know You

These forms does not obligate you or Engaged Employment to Job Coaching services. It is intended for the exchange of information only.

Adult Services/Job Coach Services

Today's Date

Adult's Information

Name

Date of Birth

Age

Gender

Address

City

State

Zip Code

Phone Number

Parent Phone Number

Which county are you located?

Have you completed high school?

Yes

High school diploma

GED

Associate's Degree

Bachelor's Degree

Are you currently employed? If yes, where and what is your work schedule?

Do you have a medical diagnosis for Autism? If no, please explain disability:

Are you your own legal guardian?

Yes

Do you drive and have access to a vehicle?

Yes

Parent or Legal Guardian Information

Parent or Legal Guardian Name

Relationship to adult requesting services

Address

City

State

Zip Code

Phone (Home)

(Cell)

Occupation

Work Phone

Other Information

How did you hear of Engaged Employment?

Please answer the following questions as honestly as possible by answering Yes or No:

Can you INDEPENDENTLY, without assistance?

Reading (approximate grade level)?

What areas of assistance are needed most? What skills need to be worked on?

53702

	Yes	No
Follow 2+ step directions?
Follow a written schedule?
Tell Time?
Make Change?
Do simple math (addition/subtraction)?
Ask for assistance when needed?

Adult Services/Job Coach Services Getting to Know You

Adult's Information

Parent or Legal Guardian Information

Other Information

About

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