Begin At Home Questionnaire
Required to participate in the Goodwill Begin At Home program
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Phone Number (Area Code First) *
Street Address *
Zip Code *
What is your birthday? *
MM
/
DD
/
YYYY
Last 4 of your social.
What department do you work in at Goodwill? *
What location are you at? (store #, contract location, ADC, etc.). *
How long have you worked for Goodwill? *
Are you currently receiving health benefits through Goodwill? *
Are you currently taking advantage of your 401K benefit? *
What gender do you most closely identify with? *
Military Status
Race/Ethnicity *
Is your primary language Spanish?
Clear selection
What is your annual household income? (Before Taxes)
Clear selection
What is your household size? (how many people are you financially responsible for?)
Please list the names and birthdays of the people currently living in your home.
Are you receiving SNAP (Food Stamps)?
Clear selection
Are you receiving TANF?
Clear selection
Do you have a disability of any of the following? Check all that apply. *
Required
Please select if any of of the following apply to you:
What computer skills do you believe you are skilled at? *
Required
Do you have permanent housing? *
Which of the following applies to your housing situation? *
Are you currently seeking or requiring new housing? *
Do you own a vehicle that brings you to and from work? *
Which of the following applies to your transportation situation. *
Do you have enough food to eat? *
Which of the following applies to your food situation *
Do you have adequate childcare? *
Required
Which of the following applies to your childcare situation *
Required
Are you able to provide yourself with the necessary clothing for work? (Uniforms) *
Which of the following applies to your clothing situation *
Have you earned a high school diploma or equivalent? *
What is your highest level of achieved education so far? *
Do you have a bank account? *
What is your current financial situation? (check all that apply) *
Required
Are mental health services important to you for either issues of diagnosed/undiagnosed mental health or substance abuse or addiction counseling? *
What mental health services could you benefit from? *
Do you need any legal aid services *
How could you benefit from legal services? *
Have you been diagnosed with a disability? *
What disability services have you used? *
Required
IF you do not have healthcare coverage through Goodwill, do you have it through another source? *
What is your current healthcare situation? *
Do you have access to the following: (Check all that apply) *
Required
Are you currently seeking medical services of any kind, including dental, vision, or audiology? *
Do you have a drivers license in good standing? *
If you do not have a drivers license, what is in your way? *
Are you affiliated with a tribe? If so, which one? *
If the services you are seeking are not listed in this questionnaire, please describe what services you are seeking.
Signature (type full name) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Goodwill Career Pathways Institute. Report Abuse
Google Forms