Goodwill Easter Seal Referral Form

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This intake and referral form is for GES clients only.

Please complete the form and click "Finish" at the end.

Thank you!

Last Name

First Name

Middle Name

Social Security Number (optional)

Street Address

Apartment #

City/State/Zip Code

Phone Number

Gender/Please Select
Male
Female

Birth Date

Country of Birth

First Language

Ethnicity/Please Select
Asian
Black or African American
Hispanic/Latino
Native American
Pacific Islander
White

Work Status/Please Select
Employed
Unemployed
Not in Labor Force

Years of Education/Please Select
0 Years
K-5
6-8
9-12
HS Diploma
GED
Post Secondary

Other NRS Reporting Info

Displaced Homemaker
Single Parent (Child/ren under 18)
Has Children in SPPS
Low Income
Disability
Learning Disability

DATA PRIVACY: Do we have permission to release this information upon request to outside agencies only? I give my permission:

Yes No

[ Finish ]