M:STL General Intake Screening Form

CONTACT INFORMATION

Who is filling out this form?

Date of Screening

Birthdate (mm/dd/yyyy)

Legal First Name

Last Name

Preferred First Name (Do you have a different name you go by?)

Secondary Phone Number

Can we text you at this phone number?

YesNo

ADDRESS

Which of these applies to you?

Street

City

State

MO, IL, etc.

Zip Code

Please explain.

What shelter?

What neighborhood do you live in?

To confirm visit this website: https://www.stlouis-mo.gov/data/address-search/index.cfm

BACKGROUND INFORMATION

Other Race

Do you identify as Latino or Hispanic?

YesNo

Is English your primary language?

YesNo

What other languages do you speak?

Do you have a disability?

YesNoDo not wish to answer

Are you deaf or have serious difficulty hearing?

YesNo

Are you an immigrant, refugee, or asylum seeker?

YesNo

What is your gender identity?

MaleFemaleNon-BinaryPrefer not to say

Have you ever served in the military?

Yes, active military (currently)Yes, reserve military (currently)Yes, prior service (veteran)No

Have you ever been diagnosed with a mental illness?

YesNoPrefer not to answer

Do you have a history of substance abuse?

YesNoPrefer not to answer

Do you have any specific job-related skills or certifications?

EMPLOYMENT

Are you able to work?

YesNo

If no, why not?

RetiredDisabledOther

Please explain:

Have you ever been employed?

YesNo

Current employment status:

UnemployedEmployed, but inconsistent work historyEmployed, but seeking better opportunityHappily employed

Were you fired, laid off or did you quit? Please explain:

What are your employment needs?

Transitional job - short-term internship to gain work skills and experienceSkilled trainingStraight to work - I have 6+ months of recent, consecutive work history, can pass drug test, has employable skillsetNo needs at this time

Have you participated in any job readiness programs before?

YesNo

Please provide details:

Why are you interested in joining the Beyond Jobs/Hire St. Louis program?

What are your primary goals for participating in the program?

Are you committed to attending the program classes at least three times a week?

YesNo

Why not?

Do you have any specific preferences or needs that should be considered in program design? (e.g. scheduling, accommodations)

HOUSEHOLD & FINANCES

How many people live at your house INCLUDING YOURSELF?

This includes anyone living at the same address/residence/location.

Do you have children?

YesNo

Are any of your children under 18?

YesNo

How many of your children are under 18?

What is your monthly income?

Do you have proof of income?

YesNo

Please explain.

LEGAL

Have you been incarcerated within the past 6 months?

YesNo

Have you been been involved in the justice-system in the past 6 months?

YesNoThis includes probation, parole, released from jail/prison, pending warrants or criminal court cases. This does not include anyone incarcerated in the last 6 months.

Do you currently have an open case in St. Louis city?

YesNo

Please explain:

Do you currently have an open case in St. Louis county?

YesNo

Please explain:

ADDITIONAL INFORMATION

Please explain other barriers:

EMERGENCY CONTACT

First Name:

Last Name:

Relationship:

Phone Number:

Please explain how you heard about us:

If a specific person referred you to Mission: St. Louis, please indicate the first name, last name, and phone number of this person below. If you don't know this information, it is okay to leave it blank.

First Name:

Last Name:

Phone Number:

Would you like to make an internal program referral for this client?

YesNo

Additional notes about client:

27+ weeks unemployed	Cultural barriers
Domestic Violence	Employment
English language learner	Ex-offender
Family Violence	Financial
Food Insecurity	Homelessness
Identification	Lacks childcare
Lacks transportaiton	Legal
Low income	Medical
Mental Health	None apply
Reading difficulty	Receiving government assistance
Single parent	Substance Use
Trauma	Other