Consumer Intake Form

First Name

Last Name

Preferred Pronoun

Phone

Email Address

Are you attending school, college, or in training? If so, what school?

Preferred Counselor? Preferred Counselor? Female Male No preference

Career Plus Agency Meeting Preferences Career Plus Agency Meeting Preferences Prefer to Meet in Person Zoom Video Meeting Hybrid, Combination of both

Please list any training, degree or certifications below:

Days of the Week you are available? Days of the Week you are available? Monday Tuesday Wednesday Thursday Friday

List one - three careers or jobs you have considered in the last year or so?

Available Transportation? Available Transportation? Yes No

Do you have access to the Internet? Do you have access to the Internet? Yes No

Are you willing to accept Non-Paid Internships? Are you willing to accept Non-Paid Internships? Yes No