Learning Needs Screening

INTERVIEWER NAME:

INTERVIEW DATE:

CLIENT NAME:

DATE OF BIRTH: GENDER: MALE FEMALE

SOCIAL SECURITY NUMBER:

HOW MANY YEARS OF SCHOOL HAVE YOU HAD?

CHECK ALL EARNED:

• HIGH SCHOOL DIPLOMA
• GED
• TECHNICAL/VOCATIONAL CERTIFICATE
• AA DEGREE
• OTHER (SPECIFY):

WHAT KIND OF JOB WOULD YOU LIKE TO GET?

DO YOU HAVE EXPERIENCE IN THIS AREA? YES NO

WHAT MAKES IT HARD FOR YOU TO GET OR KEEP THIS KIND OF JOB?

WHAT WOULD HELP?

BEFORE PROCEEDING TO THE QUESTIONS, READ THIS STATEMENT ALOUD TO THE CLIENT:

The following questions are about your school and life experiences.

We're trying to find out how it was for you (or your family members) when you were in school or how some of these issues might affect your life now. Your responses to these questions will help identify resources and services you might need to be successful securing employment.