Client Referral

Race*  (use Ctrl for 1+)

AsianBlack/AfricanAmerican ChineseHmongNativeHawaiian/Pacf IsldrIndian/Alaska NativeWhiteOtherDon't KnowRefused

Primary Language* 
(use Ctrl for 1+)

EnglishHmongSpanishFrenchGermanChineseOther

Veteran* 

--Select--YesNo

Other

Annual Income

--Select--$0-10,830$10,831-14,570$14,571-18,310$18,310-22,050$22,051-25,790$25,791-29,530$29,531-33,270$33,271-37,010$37,011-40,750Above

In accordance with the Americans with Disabilities Act, are there any
disabilities or special accomodations that we should be aware of?* 

--Select--YesNo  If Yes, please describe below:

Pay Inverval (How often do you get paid?)

--Select--WeeklyBi-WeeklyMonthlyYearlyQuarterly

Health Insurance

--Select--BadgerCareBadgerCoreMedicaidPrivateOther
Other:

Housing Status*

--Select--Literally HomelessImminently losing housingUnstably housed at risk losing houseStably HousedDon't KnowRefused

Family Type*

--Select--UnaccompaniedFoster ParentSingle ParentTwo Parent HouseholdAdults with no childrenUnknown

Are you the head of household?*

--Select--YesNo

If No, please select:
--Select--SpouseChildRoommateOther Other:

Education level

--Select--No SchoolingNursery School - 4th Grade5th or 6th Grade7th or 8th Grade9th Grade10th Grade11th Grade12th Grade - No DiplomaHigh School DiplomaGEDPost Secondary School4 years collegeGraduate SchoolUnknown

Career Dev / Welcome Ctr
Skills Enhancement (E&T)
W-2 Elig Assessmt*

For all areas checked please specify details of client's needs/situation if known