Young Adult Program Application and Initial Assessment - The Center on Colfax

Young Adult Program Application & Initial Assessment

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Primary Phone(Required)

Mobile or Landline?(Required)

Mobile

Landline

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Pronouns(Required)

Mark all that apply

They/Them

He/Him

She/Her

Otherwise Specified

Prefer Not To Say

Pronouns - Otherwise Specified(Required)

Gender Identity(Required)

Mark all that apply.

Gender Identity - Otherwise Specified(Required)

Sexual Orientation(Required)

Mark all that apply

Lesbian

Gay

Bisexual

Heterosexual

Pansexual

Asexual

Questioning

Otherwise Specified

Prefer Not To Say

Sexual Orientation - Otherwise Specified(Required)

Race/ Ethnicity(Required)

Click All That apply.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latina/o/x

Native Hawaiian or Other Pacific Islander

White

Otherwise Specified

Prefer Not To Say

Race/Ethnicity Otherwise Specified(Required)

Disability Status(Required)

Check All That Apply.

Disability Status - Other Health Impairment(Required)

Living Situation(Required)

Living Situation - Otherwise Specified(Required)

Human Services To Which You Have Been Connected(Required)

CPS

Foster Care

CSAS

Correctional System

Residential Facility

Otherwise Specified

None

Prefer Not To Say

Human Services To Which You Have Been Connected- Otherwise Specified(Required)

Level of Education Completed(Required)

Elementary School

Middle School

High School Graduate / GED

Community College

Some College/ Univeristy

College/University

Post Graduate

Otherwise Specified

Level of Education Completed- Otherwise Specified(Required)

Are You Currently In School?(Required)

Yes

Prefer Not To Say

Are You in School In-Person, Online, or Are YouHome-Schooled(Required)

In-Person

Online (Online Teachers Manage the Student's Studies from Afar Within a Structured Curriculum

Home School (Parent or Guardian Acts as Full-Time Instructors) while in online schooling

Prefer Not To Say

Name of School(Required)

Have You Completed a GED?(Required)

Yes- Completed

No - Not Interested

No - Interested in GED

No - Interested in Job Training

No - Interested in Job Training & GED

Employment(Required)

Employed - Full Time

Employed - Part Time

Not Employed

Student

Internship/ Student Worker

Retired

Household Income(Required)

If you prefer not to disclose, please type "Prefer Not To Say"

Food Security(Required)

High Food Security (It is easy for me to afford 3 meals a day)

Marginal Food Security (It is relatively easy for me to afford 3 meals a day)

Low Food Security (I have a hard time affording food)

Food Insecure (It is difficult for me to afford food and have to skip multiple meals)

Prefer Not to Say

Health Insurance Status(Required)

Private Health Insurance (Individual Policy or Provided by Employer)

Parent/Guardian's Health Insurance

State Health Insurance

No Health Insurance

Prefer Not to Say

Health Care System Service Usage(Required)

Highly Engaged: I am actively engaged in the health care services I have and have minimal or no barriers to accessing health care that I need

Moderately Engaged: I am somewhat engaged in health care services but experience access or barriers to having health care

Low Engagement: I do not engage in health care at all due to lack off access and barriers to having health care

Prefer Not to Say

What is Your Support System(Required)

Check All That Apply

I have supportive family

I have supportive friend group(s)

I am supported by my school’s staff, if applicable (teacher/professor/staff)

I do not have a support system and seeking to find one

I seek to find more supportive people in my life

prefer not to say

Assessment

LGBTQ+ Knowledge

Do you understand what gender identity is?(Required)

Yes

Somewhat

Do you understand what sexual orientation is?(Required)

Yes

Somewhat

Are you knowledgeable about LGBTQ identities and the people in the community?(Required)

Yes

Somewhat

Are you knowledgeable about the issues surrounding the LGBTQ identifying people of color?(Required)

Yes

Somewhat

Do you understand what intersectionality is?(Required)

Yes

Somewhat

Are you knowledgeable about different cultures surrounding the LGBTQ community?(Required)

Yes

Somewhat

Do you understand what gender expression is?(Required)

Yes

Somewhat

School & Employment

Have you ever made a resume?(Required)

Yes

Have you ever filled out a job application?(Required)

Yes

Do you have a resume that you are confident with using?(Required)

Yes

Somewhat

Have you ever completed a job interview?(Required)

Yes

Have you considered attending college/university or vocational school?(Required)

Yes

I am currently enrolled

Do you know what a FAFSA form is?(Required)

Yes

Do you know how to fill out and locate a FAFSA form?(Required)

Yes

Finances

Do you know how to open a bank account?(Required)

Yes

Are you familiar with ways to save money?(Required)

Yes

Somewhat

Are you familiar with filling your taxes each year?(Required)

Yes

Somewhat

Do you know how to identify scammers?(Required)

Yes

Do you know how credit ratings work?(Required)

Yes

Somewhat

Do you know how to create emergency funds for when you need it in the future?(Required)

Yes

Life Skills

Do you know how to locate the nearest hospital to your home?(Required)

Yes

Are you able to identify at least 3 ways to keep yourself safe when living independently(Required)

Yes

Do you know how to plant produce indoor or outdoor?(Required)

Yes

Do you know how to do basic car repairs such as changing tires, oil checking car fluids?(Required)

Yes

Somewhat

Race Biases

Do you know the definition and meaning of “implicit bias”?(Required)

Yes

Do you know what systemic oppression is and how it affects people of color?(Required)

Yes

Do you know what the definition of “intersectionality”?(Required)

Yes

Are you aware of how privilege and lack having thereof affects different people?(Required)

Yes

Somewhat

Do you know how we hold stereotypes of different people and how that affects people of color?(Required)

Yes

Somewhat

How Did You Learn About The Center on Colfax?(Required)

Search Engine

Social Media

Friend or Coworker

Other