Work and Life Essentials; Intake and Assessment.
Complete this Intake and Assessment form to help us assist you in your journey.
First Name *
Last Name *
Address
City
State/Zip Code
Email *
Cell Number *
What is your best method of contact?
Clear selection
Gender Identity *
Ethnicity *
Race *
 Level of computer knowledge *
Level of Microsoft Word *
Level of Power Point *
Level of Excel *
Would you be interested in attending virtual training? *
What time can you meet for future virtual training? *
What day(s) are you available for training? *
Describe your status *
Required
Are you able to attend Zoom or face-to-face meetings? *
Please check the number of people living in your household. *
Required
How would you best describe your household income? *
Was your work life affected by the COVID-19 pandemic?
Clear selection
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