LOCAL INTAKE ASSESSMENT - Section 18 - Employment

Local Name

First Name

Last Name

Currently Employed

Unemployed

Full-Time

Part-Time

Place of employment if any

Supervisor's Name (if any)

First Name

Last Name

Supervisor's Contact (if any)

Satisfaction with current employment

Do you have an active TWC case?

yes

If yes, name of counselor

First Name

Last Name

If Local is currently employed, what supports are in place for long-term success?

Does local need assistance finding a new job?

Yes

If yes, areas of interest?

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