Client intake form

Annual statistical report. Demographic information


    WhiteBlack/African AmericanAmerican Indian/Alaska NativeAsian/Pacific IslanderOther/Race/Origin









    SingleMarriedDivorcedWidowedDomestic PartnershipSeparated






    I have a carI ride the busI have a ride

    SSI/DisabilityPaycheckTANFFood Stamps/SNAPChild SupportAlimonyOther




    The following barriers prevent me from obtaining employment/education: (check all that apply). See the below definitions.

    EMPLOYMENT HISTORY (start with the most recent employer)

    [textthird-job_title placeholder "Job title"]


    EDUCATION HISTORY (start with the most recent education)


    Unemployed/Dislocated Worker. Individuals who have previously been in the labor force but who have fast their jobs due to layoffs, plant
    closings, downsizing, or circumstances.

    Under-employed. Person who self-reports that they currently hold a job but do not work enough hours or earn enough to cover their expenses or not doing work that makes full use of their skills and abilities.

    Blindness or Other Visual Impairment. Blindness refers to the total or partial loss of sight. Legal blindness refers to an individual
    who has a visual acuity of 20/200 or less in the better eye with correction, and/or individuals whose visual field does not exceed 20

    Deafness or Hearing Impairment. Hard of hearing describes any degree of hearing loss, from light to profound, in a person who may
    benefit from a hearing aid or some other assistive device. Deafness refers to profound hearing loss in a person who does not have the
    ability to discriminate speech aurally.

    Physical Disability.This category includes orthopedic disabilities, arthritis, pulmonary, and cardiac disorders. An orthopedic disability
    is a disability associated with bone and muscles around the bone. Examples include individuals with amputations,·back and spinal
    cord injuries. Arthritis and rheumatic disease refer to over 100 different diseases that cause inflammation and pain in the joints and
    can result in loss of mobility. Pulmonary and cardiac disabilities refer to diseases of the lungs and or respiratory system and diseases
    of the heart or blood vessels respectively.

    Neurological Disability. An impairment of the brain and nervous system, this category includes all individuals with head injuries
    including Traumatic Brain Injury (TBI), Parkinson's disease, Alzheimer's disease, Multiple sclerosis, and Epilepsy.

    Emotional Disability/History of Mental Illness. A disability that substantially impairs a person's thought, perception of reality,
    emotional process, or judgment. Examples if Psychiatric/emotional disabilities include schizophrenia, bipolar disorder, obsessive- compulsive disorder, anxiety disorders, and depression.

    Learning Disability. A disability that impacts the understanding or use of language spoken or written, and that may manifest itself in
    an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. Learning disabilities include Dyslexia,
    Aphasia, Developmental Writing Disorders, and Central Auditory Processing Disorders, ADD ADHD.

    Developmental Disability. A diverse group of cognitive, psychological, physical, sensory, and speech impairments that begin anytime
    during development up to 18 years of age. Mental retardation is the most common developmental disability. This category also
    includes Down's syndrome, and fetal alcohol syndrome.

    Autism. Autism spectrum disorder {ASD) and autism are both general terms for a group of complex disorder of brain development.
    These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication, and
    repetitive behaviors. They include autistic disorder, Rett syndrome, childhood disintegrative disorder, pervasive developmental
    disorder-not otherwise specified (POD-NOS) and Asperger syndrome.

    Other disabling conditions. Other disabling conditions are not described above.

    History of Substance Abuse Is defined as the history of loss of control over use of a mood altering substance and subsequent use despite negative consequences. This category includes drug and alcohol dependency.

    Lack of Transportation. A person who self-reports that they lack affordable, safe and/or accessible transportation options.

    Lack of Child Care Services. Person who self-reports that they lack affordable and/or accessible quality child care services.

    Lack of Literacy Individuals who lack basic reading or comprehension skills in their primary language.

    Lack of GED/ High School Equivalency. Individuals who lack basic education to the level of high school equivalency.

    Lack of Post-Secondary Credential. A post-secondary credential is awarded in recognition of an individual's attainment of
    measurable, technical, or occupational skills, necessary to obtain employment or advance within an occupation.

    Refugee. Person who self-reports they are from outside the United States and have been granted.refuge status by the United
    States because they have been persecuted or fear they will be persecuted on account of race, religion, nationality, and/or
    membership in a particular social group or political opinion.

    Immigrant. Person who self-reports they were born to non-U .S. citizen persons outside of the U.S. and have been granted the
    right to reside permanently in the United States and to work without restrictions in the United States.

    Homeless. An individual who: (1) lacks a fixed, regular and adequate residence; or (2) has a primary residence that is: (a) a supervised,
    publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate
    shelters and transitional housing for the mentally ill); (b) an institution that provides a temporary residence for individuals intended to
    be institutionalized; or (c) a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human
    beings. (McKinney Act (P.L. 100 - 77, sec. 103(2) (1) 101 sat. 485 [1987])).

    Person with a Criminal Background. Any adult or juvenile who is or has been subject to any stage of the criminal justice process and
    who requires assistance in overcoming barriers to employment resulting from a record of arrests or convictions.

    At-Risk Youth. Individuals 16-24 who may be single parents, gang members, school dropouts and/or who exhibit behavior patterns
    which pose barriers to social Integration and employment.

    Incumbent workers. Workers who currently hold a job who are often seeking to upgrade their skills to obtain a better job or maintain the skills needed for their current job.

    Working poor. An individual defined as someone in the labor force, but earn less than 200% of the poverty level.

    Older Worker. Individuals age 55 or above.


    For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby voluntarily consent to the photographing of myself and the recording of my voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. I understand that the term "photograph" as used herein encompasses both still photographs and motion picture footage. This document was offered to be verbally
    conveyed to me, upon my request.

    I further consent to the reproduction and/or authorization by Goodwill Industries of North Louisiana Inc. to reproduce and use said photographs and recordings of my voice, for use in all domestic and foreign markets for a period of no longer than six (6) years from authorized date, unless I revoke it prior to that time. I understand that I may revoke this authorization by submitting a written request to Goodwill Industries of North Louisiana Inc., 800 W. 70th Street, LA 71106. I understand that, if I revoke this authorization, my revocation will not have any effect on actions already taken by Goodwill Industries of North Louisiana in reliance on my authorization. Further, I understand that others, with or without the consent of Goodwill Industries ofNmih Louisiana Inc. may use and/or reproduce such photographs and recordings.

    I hereby release Goodwill Industries of North Louisiana Inc., and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.

    The information may be used/disclosed in the following manner:
    •public relations and press materials
    •promotional videos
    •across social media platforms (Facebook, Twitter, Instagram, Linked In, TikTok)
    •advertisements, documentation and print collateral
    •broadcast (television)
    •display on the internet on the Goodwill website
    •presentations given by Goodwill Workforce Development and other authorized Goodwill staff
    •training materials

    By voluntarily signing this form, I understand that I wll be enrolled into a Goodwill Industries of North Louisiana Workforce Development Program and all statistical information collected can be used to seek future funding and/or reported to Goodwill Industries International.*

    By signing this agreement, you are consenting to any authorization of usage unless specified here:

    Our mission

    Goodwill Industries improves people’s lives through the power of work.

    The purpose and vision of Goodwill is to ensure that every person finds a meaning, purpose and value in life by securing employment. This brings about change in not only the person, but the family and the community at-large.