Job Seeker Pre-Intake Questionnaire Step 1 of 13 7% Introduction This questionnaire will help us get to know you better and understand how we can support your employment goals. You can save your progress at any point and restart where you left off. Dates should all be typed in the format MM DD YYYY (month, day, year) You may fill this form out alone or with support from us, a family member, a support worker, or a friend. Important – All information collected is kept confidential according to the privacy act and is only shared with your written consent. If you already have a portal account, please log in before completing this form. You are required to create an account when you submit this form. Portal RegistrationPlease create an account for our client portal. This will allow you to fill out further paperwork if you are eligible for one of our programs. Username(Required)Password(Required) Enter Password Confirm Password Strength indicator Today's Date Month Day Year Are you completing this form on behalf of the job seeker? No, I’m filling it out for myself Yes – please complete the contact information below I need help to complete this form Other (please explain below) Other Completion TypeSupport Person Name First Last Relationship to Job SeekerSupport Person Phone NumberSupport Person Email Address Would you like a copy of this form sent to your support person? Yes No If you need our help filling out this form, please enter your contact below and the closest town to where you live then press the submit button. We will contact you to set up a time to fill out the form. Contact Information(Required)Email and/or phone number where we can contact you.What town do you live closest to?(Required)DundalkFleshertonHanoverMarkdaleMeafordOther (please specify below)VirtualIf you prefer a virtual meeting, please select it from the list.Other Town(Required) Your Personal InformationName as it appear on your SIN Card (Social Insurance Card)(Required) First Last Preferred Name (if different than your legal name) First Last Pronouns she/her/hers he/him/his they/them/theirs Other Date of Birth Month Day Year Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code No Address I have no fixed address.PhoneEmail What is the best way to connect with you? (please rank from best at the top to worst at the bottom)TextEmailPhoneDrag the best way to communicate with you to the top and the least favourable way to the bottom.How would you like to be reimbursed for expenses?(Required) Direct Deposit eTransfer Cheque by Mail Email address for eTransfers(Required)Void Cheque (pdf only)(Required)Accepted file types: pdf, Max. file size: 64 MB.This field is hidden when viewing the formVoid cheque uploaded?This is used by the job seeker expense form to let the user know that they have previously uploaded a void cheque. The custom snippet . Added 2025.03.20 0 – no 1 – yesAddress you would like cheques sent to (if different from above)(Required) , , , Are you eligible to work in Canada? Yes – Citizen Yes – Permanent Resident Yes – Refugee Yes – Work VISA No In the past 12 months, have you worked with another Employment Service Provider (ex, YMCA, VPI, LEADS)? Yes No Not Sure Service Provider Name (if known)Employment Advisor Name (if known)Do you receive assistance from a family member or a support worker? (ex. finances, daily activities, or social activities) Yes No Unsure Family or Support Worker NameFamily or Support Worker Phone Number Establishing Your Starting Point For immediate help with your basic needs, call 211 or find local support in Grey and Bruce counties here.Please review the list below and choose any of your basic needs that are not being met. Food Housing Clothing Medication Assistive devices (ex: glasses) Childcare or dependent care Transportation Communication (internet and a computer, smartphone) Other (please specify below) Other Basic NeedsWhat is your main source of income?(Required)No source of incomeEIWSIBOW applied or receivingODSP applied or receivingdependant of OW or ODSP recipientCrown WardEmploymentSelf-EmploymentOther Specify Below Do you have access to reliable transportation? No Yes, I have my own vehicle Yes, I have a family member or friend who drives me Sometimes What best describes your housing situation?Renting privateRenting subsidizedBoarding or lodgingHomeownerLiving with family or friendsInstitutionTemporary secondary residenceBand owned homeHomeless transientEmergency hostelAt risk of being homeless in the next month Employment barriers that stop me from getting or keeping a job (please check all that apply):(Required) Limited work experience Living in poverty and can’t meet my basic needs or access start-up funds to get to work Self-disclosed or diagnosed disabilities Lack of care for dependents (children or adults) Reading, writing and math skills Mental health challenges Addictions challenges Criminal background New Canadian Member of a minority group Lack of reliable transportation Other (please specify below) Prefer not to answer None Other Barrier(s) EmploymentAre your ready to get a job in the next three months? Yes No Unsure Do you have a digital copy of your resume? Yes (please upload it below) No Resume UploadMax. file size: 64 MB.Does your resume need updated? Yes No Unsure Please explain why you need help with your employment goals: Someone told me to get help getting a job I don’t know how to get a job, or I have never worked before I have not been able to find a job on my own I am new to the area and don’t know the local job market I need help getting back into the workforce I need help making job goals I find it hard to keep a job Other (please specify below) Other Meeting SupportsPlease choose all of the supports below that will help you to be successful in our meetings.Virtual Meeting Zoom tutorial Closed captions or subtitles Increase font size when sharing the screen A video of the meeting A transcript of the meeting Other (please specify below) Other Virtual Meeting SupportIn-Person Meeting Wheelchair accessible (barrier free) Scent-free environment Private room (noise and sensory reduction) Service animal Body or mental breaks Other In-Person Meeting SupportIn-Person & Virtual Meetings – Communication Aids Bring a support person to the meeting Assistive technology (computer tablet or smartphone, and software such as screen readers) Scribe (writing and typing) for completing documents Repeating or rephrasing instructions Verbal recap of the meeting Written recap of the meeting in bullet points Written recap of the meeting in a paragraph Use large text in written communication Share notes of the meeting with your support person Other (please specify below) Other Communication Support Is there anything else you would like us to know before the intake meeting?Newsletter I would like to sign up for the LDE monthly newsletter (you can unsubscribe at any time).Please note that if you do not sign up for the newsletter, you will still get emails from us every now and then about upcoming events you may be interested in. You can also unsubscribe from these emails as well.EmailThis field is for validation purposes and should be left unchanged.
