Workforce Villages Prescreening Application

Today’s Date *

Your Name *

Your Name

First

Middle

Last

Phone

Preferred Name (if different from above)

Email *

Social Security Number *

Date of Birth *

Phone Number *

Do you have a cell phone? *

Yes

Cell phone type: *

Personal cell phone

Government cell phone

Your preferred contact method *

Phone call

Text

Were you referred to us by another agency? *

Yes

If yes, which agency referred you? *

If you were not referred by an agency, how did you hear about Workforce Villages? *

Have you ever been a client of the Workforce Villages previously known as Employment Bridge? *

Yes

When you left the Workforce Villages Program was your exit *

Successful

Unsuccessful

Please tell us more about your successful Workforce Villages exit:

Do you have $750 in savings? *

Yes

Why have you become unhoused again? *

What have you learned? *

Why should you be reconsidered? (supporting documents recommended) *

If in recovery, how is it going? How are you obtaining sobriety support, if necessary? *

If sobriety was an issue, please provide documentation regarding your treatment. *

Please tell us more about your unsuccessful Workforce Villages exit:

Do you have $500 in savings? *

Yes

Why were you exited? *

What have you learned? *

Why should you be reconsidered? (supporting documents recommended) *

If in recovery, how is it going? How are you obtaining sobriety support, if necessary? *

If sobriety was an issue, please provide documentation regarding your treatment. *

Current Housing

Are you currently experiencing homelessness? *

Yes

If yes, where are you staying? *

Shelter

Friend

Family

Street

OtherOther

Have you ever been unhoused before? *

Yes

If yes, how many times have you been unhoused? *

Address *

City *

State *

Zip Code *

What was your prior living situation before becoming unhoused? *

When was the last time you had a lease in your name? *

Have you ever been evicted? *

Yes

If you have been evicted, when? *

Demographics

Are you in HMIS? *

Yes

Unknown (explain)Unknown (explain)

If yes, HMIS # *

Ethnicity *

Indigenous

Asian

Black

Hispanic/ Latino

White

Native Hawaiian/ Islander

OtherOther

Gender *

Female

Male

Nonbinary

I choose not to say

OtherOther

Are you a part of the LGBTQ+ community? *

Yes

I choose not to say

Are you a veteran or active military? *

Yes

Are you receiving disability benefits? *

Yes

Are you fleeing a domestic violence situation? *

Yes

Do you have any dependents? *

Yes

If yes, how many dependents do you have? *

What is the highest degree that you have completed? *

No degree

GED

High School Diploma

Trade School/ Associates

Bachelor’s Degree

Master’s Degree

Doctorate

If no degree, what is the highest grade level you completed? *

8th grade

9th grade

10th grade

11th grade

12th grade

Do you have a Driver’s License? *

Yes

What is your primary form of transportation? *

Public transportation

Your own car

Shared car

Do you have substance use challenges? *

Yes

If yes, what type (gambling, alcohol, drugs, etc.) *

If these are former challenges, how long have you been in recovery? *

Employment & Benefits

Are you receiving SNAP/ EBT benefits this month in Arizona? *

Yes

If yes, how much? *

Are you receiving WIC benefits this month in Arizona? *

Yes

If yes, how much? *

Employer Name *

Employer Address *

Employer Address

City

State/Province

Zip/Postal

What city do you work in? *

Your work cross streets *

Your start date *

Your hourly rate of pay *

Benefits offered? (even after 90 days) *

Yes

How often do you get paid? *

Weekly

Twice a month

Biweekly / every other week

Monthly

Is your position: *

Temporary

Permanent

If temporary, is it temp to hire? *

Yes

Can you provide proof? *

Yes

Do you have a copy of your last paycheck? *

Yes

If no, when will you receive one? *

Do you have any other income? (SSI, SSDI, etc.) *

Yes

If yes, what type? *

Are you on AHCCCS (state health insurance)? *

Yes

If yes, which plan? *

Arizona Complete Health

Arizona Complete Health – SMI

Banner University Family Care

Care 1st

DCS/ CMDP

Magellan Complete Care

Mercy Care Plan

Mercy Care Plan – SMI

Steward Health Choice Arizona – SMI

Steward Health Choice Arizona

If no, do you have any other insurance? *

Yes

If you do have other insurance, is it: *

Employer-based

Private pay

Living Arrangement & Background

Do you have a pet? *

Yes

If yes, are they registered and trained as a support animal? *

Yes

Would there be any occasion for your to have a guest in your room during the duration of the program? *

Yes

If yes, please explain: *

Do you have any existing medical conditions/scheduled surgeries/doctors’ appointments that will interfere with your work for the duration of the program? *

Yes

If yes, please explain: *

Are you willing to complete a background check for the Workforce Village Team to assist you with possible future challenges with employment or housing? *

Yes

Do you have any criminal background such as outstanding warrants / past or current felonies or misdemeanors? *

Yes

If yes, please explain: *

Do you have any upcoming court dates within the duration of the program? *

Yes

Are you on probation or parole? *

Yes

If yes, what is the name and number of your probation or parole officer? *

If yes, what are your probation or parole requirements? *

Do you have any substantial time off for work planned for the duration of the program, such as vacation? *

Yes

If yes, please explain: *

Finances

Are any of your wages being garnished? (i.e. court fees, medical bills, child support, alimony, etc.) *

Yes

Do you have any other outstanding debts? *

Yes

Garnished wages $/ month *

Legal fees $/ month *

Car payment $/ month *

Car insurance $/ month *

Storage unit $/ month *

Student loans $/ month *

Medical bills $/ month *

Health insurance $/ month *

Cell phone $/ month *

Credit card $/ month *

If you have existing credit cards, by completing the intake into the Workforce Villages Program, do you agree to not use your credit cards without authorization during your program stay? *

Yes

Do you have a bank account? (Chime, NetSpend, CashApp, Wisely, etc. are not eligible for a savings and/or checking account) *

Yes

If yes, which one(s)? *

Are you willing to use and/or open a Bank account strictly for savings for the Workforce Villages Program within the next 10 days? (Client has full control over account) *

Yes

Do you need assistance in finding a financial institution or opening an account? *

Yes

Have you ever budgeted money before? *

Yes

What is your biggest concern about budgeting? *

In addition of putting 80% of your paychecks into savings, are you willing to put 100% of any tax refunds, military payments, stimulus checks or social security benefits you are receiving or may receive into savings while in this program? *

Yes

Are you committed to sharing information throughout this process, regarding losing a job, not maintaining sobriety, etc.? *

Yes

Do you feel comfortable with showing your Workforce Villages Team Member your bank balances, account activity, and paystubs weekly? *

Yes

Are you willing to meet with our Workforce Village Team weekly to work on your goals? *

Yes

Please upload your employment offer letter & paystub(s)

Maximum file size: 516MB

If you are human, leave this field blank.

Start Over

Please tell us more about your successful Workforce Villages exit:

Please tell us more about your unsuccessful Workforce Villages exit:

Current Housing

Demographics

Employment & Benefits

Living Arrangement & Background

Finances

Social Media

Donate

Programs

Subscribe to Our Newsletter

Please tell us more about your successful Workforce Villages exit: arrowup6

Please tell us more about your unsuccessful Workforce Villages exit: arrowup6

Current Housing arrowup6

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Employment & Benefits arrowup6

Living Arrangement & Background arrowup6

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Social Media

Donate

Programs

Subscribe to Our Newsletter

Please tell us more about your successful Workforce Villages exit:

Please tell us more about your unsuccessful Workforce Villages exit:

Current Housing

Demographics

Employment & Benefits

Living Arrangement & Background

Finances