Date: Today’s date	Agency: Referring Agency
Name: Client’s Name	Contact: Your Name
Email: Client’s email	Email: Your email
Phone: Client’s Phone	Phone: Your phone
Preferred Contact: Choose an item.	Preferred Contact: Choose an item.

Email completed form to contact@lifeability.net or fax to 971-373-8877.

Special Considerations

Addiction

Criminal history

Currently Employed

Employment history

Family responsibilities

Health issues

Homelessness

Learning Disability

Location needs

Mental Health

Mobility Impaired

Physical Limitations

Public Transportation

Rental history

Sex offender

Other: _____________

Services Requested

Evaluation & Assessment

Barriers to employment

Career options

Job Search readiness

Labor Market Research

Life Skills (knowledge)

Online Presence

Other: ______________

Individual training

10 year career map

Appearance

Applications (online)

Applications (paper)

Barriers (consultation)

Crisis Planning

Handling Hurdles

Interview Prep

Job Search

Job search w/technology

Networking

Online Presence

Problem Solving

Professional Attitude

Resume Review/Update

Resume Writing

Time management

Virtual Job Club

(advanced/daily)

Other: ______________

Small Group training

Tenant education

(Rent Well)

Handling Hurdles

Time Management

Presenting/Representing

Job Club

(weekly)

Other: ______________

Comments: Any additional information?