PROGRAM IN-TAKE:  For ages 11 & Up
Hello, thank you for visiting our website. This in-take form is for anyone who is seeking FREE Community Resources, does not matter what age you are, from youth, disabled, senior citizens, we are here to provide the resource. This in-take is also for At-Risk Young Adults Ages (11-29) FREE Supportive Services which means we work one-on-one with At-Risk Young Adults needing assistance in seeking our program services: Education, Vocational, Life Skills and Re-Entry/Diversion services.  
We provide workshops and community resources for ages 30 & Up for Contra Costa and the surrounding counties. Our goal is to provide the support for you and your families who are in need of community services that are available. We do not turn anyone away. Once you complete the in-take, you will be contacted within five business days. The information you provide is solely for the purpose to assist us in how to give you the help you need to meet your goals, this information will NOT be shared with any agency and/or persons.
***PLEASE BE SURE TO SPELL YOUR E-MAIL AND PHONE NUMBER ACCURATELY***
Thank you so much!
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TODAY'S DATE *
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HOW DID YOU HEAR ABOUT US? *
Who is filling out this In-Take? *
Required
YOUNG ADULT'S  FIRST NAME **Following questions are re: Youth & Young Adult only *
YOUNG ADULT'S  LAST NAME *
GENDER *
DATE OF BIRTH *
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AGE *
SPOKEN LANGUAGE(S) *
HOW DO YOU WANT TO BE CONTACTED? *
Required
IF YOU CHOOSE TO BE CONTACTED BY PHONE, please be sure the you write in the "correct" number.
IF YOU CHOOSE TO BE CONTACTED BY E-MAIL,  PLEASE SPELL IT ACCURATELY,  SO WE CAN SEND YOU APPOINTMENT AND UPCOMING EVENTS INFORMATION.
ETHNICITY *
ARE YOU A U.S. CITIZEN?  THERE ARE FREE PROGRAMS TO HELP YOU AND YOUR FAMILY MEMBERS  (THIS INFORMATON WILL "NOT" BE SHARED WITH ANY AGENCY NOR PERSONS WITHOUT YOUR CONSENT). *
WHAT IS YOUR ANNUAL INCOME (ALL OF OUR SERVICES ARE FREE)? *
WHICH COUNTY DO YOU LIVE IN, WHETHER YOU ARE HOMELESS OR NOT, THIS WILL "NOT" AFFECT YOU IN RECEIVING SERVICES? *
WHICH CITY DO YOU "CURRENLTY" RESIDE IN, WHETHER YOU ARE HOMELESS OR NOT (THIS WILL NOT AFFECT YOU RECEIVING SERVICES)? *
MONDAYS - Time you are available for us to call or meet. Write "none" if no answer. *
TUESDAYS - Time you are available for us to call or meet. Write "none" if no answer.
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WEDNESDAYS - Time you are available for us to call or meet. Write "none" if no answer.
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WEDNESDAYS - Time you are available for us to call or meet. Write "none" if no answer.
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THURSDAYS - Time you are available for us to call or meet. Write "none" if no answer.
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FRDIDAYS - Time you are available for us to call or meet. Write "none" if no answer.
SATURIDAYS - Time you are available for us to call or meet. Write "none" if no answer.
PLEASE SELECT BELOW WHICH YOU WOULD LIKE TO ACCOMPLISH (CAN SELECT MORE THAN ONE). *
Required
DO  YOU  KNOW IF YOU HAVE A 504 or I.E.P. FROM SCHOOL? *
DID YOU KNOW YOU CAN ENROLL INTO A COMMUNITY COLLEGE, OR WORK AND EARN EXTRA CREDITS? *
IF YOU ARE ATTENDING A SCHOOL, PLEASE SELECT ONE OR MORE BELOW.  PLEASE SELECT ALL THAT YOU HAVE ATTENDED IN PAST 4-YEARS. *
Required
WOULD YOU LIKE A CAMPUS TOUR TO LEARN  ABOUT HOW TO ENTER INTO COMMUNITY COLLEGE? *
DO YOU HAVE ACCESS TO A LAPTOP OR DESK TOP COMPUTER  TO USE ZOOM? *
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