INTAKE INTERVIEW GUIDE by owen213

VIEWS: 134 PAGES: 4

									INTAKE INTERVIEW GUIDE

PERSONAL INFORMATION
                                                  Are you known by
Name: _______________________________________ any other name?: ______________________________________
Address While Attending School: ______________________________________________________________________
Telephone: (home)_______________________________________ (message left)____________________________
Date of Birth: ______________________________________________ Sex: (female) (male)
Social Insurance Number: ________________________________
Marital Status:        Single          Married        Common Law
                       Separated Divorced Widowed
Number of Dependents: ___________________________


GOALS:
  1. Why have you come to this program?
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     ________________

   2. What is it you want to be able to do?
      _________________________________________________________________________________________
      _________________________________________________________________________________________
      ________________

   3. Do you have a career goal? Yes              No
      If yes, what is it?
      _____________________________________________________________________________

EDUCATION:
  1. What was the last grade in school that you completed?
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     ________________

   2. How old were you when you left school?
      __________________________________________________

   3. Why did you leave school?
      _________________________________________________________________________________________
      _________________________________________________________________________________________
      ________________
    4. What good experiences did you have in school?
       _________________________________________________________________________________________
       _________________________________________________________________________________________
       ________________

    5. What not so good experiences did you have in school?
       _________________________________________________________________________________________
       _________________________________________________________________________________________
       ________________

    6. What subjects did you enjoy?
       ______________________________________________________________

    7. What subjects did you find difficult?
       ______________________________________________________

    8. Did you receive any special help when you were in school (such as tutoring,
       resource room, and special classes)? Yes No
       What kind of help did you
       receive?_________________________________________________________

    9. Have you ever been told that you had a learning disability? Yes No
       If yes, what kind of learning disability?
       ___________________________________________________
       _________________________________________________________________________________________
       ________

    10. Have you attended any other education or training programs since you left
        school?
        If yes, please list them:
        _____________________________________________________________________

________________________________________________________________________________________________

    11. Did you like these programs? Why or why not?
        _________________________________________________________________________________________
        _________________________________________________________________________________________
        _______________

WORK HISTORY:
  1. Are you working now? Yes No Full-Time Part-Time
     If yes, what kind of work are you doing?
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     ________________
2. What jobs / volunteer work you have done in the past?
   Job__________________________________ Date Began_____________            Date
   Left_____________
   Reason for leaving
   _________________________________________________________________________________________
   ________
   Job__________________________________ Date Began_____________            Date
   Left_____________
   Reason for leaving
   __________________________________________________________________________
   Job__________________________________ Date Began_____________            Date
   Left_____________
   Reason for leaving
   __________________________________________________________________________

3. What jobs did you enjoy doing the most?
   _________________________________________________________________________________________
   _________________________________________________________________________________________
   ________________

4. What jobs did you not like to do?
   _________________________________________________________________________________________
   _________________________________________________________________________________________
   ________________

5. What kind of work would you like to do in the future?
   _________________________________________________________________________________________
   _________________________________________________________________________________________
   ________________
LANGUAGE:
  1. Which language did you most often speak when growing up?
     _________________________________________________________________________________________
     ________
  2. Which language do you most often speak now?
     _________________________________________________________________________________________
     ________

HEALTH:
  1. Do you have any health problems that may affect your learning? Yes 
     No
        a. If yes, what are they?
           ________________________________________________________________________________
           _________

   2. Are you on any medication that may affect your learning?               Yes        
      No
         a. If yes, what medication are you on?
            ________________________________________________________________________________
            _________

   3. Do you have any vision problems? Yes              No
         a. If yes, what are they?
            ________________________________________________________________________________
            _________

   4. .Do you have any hearing problems?             Yes         No
         a. If yes, what are they?
             ________________________________________________________________________________
             _________

								
To top