Find a Program - Goodwill of Central Iowa

Thank you for your interest in our program!

Before completing the form, please make sure you meet the following criteria:

ADMISSION CRITERIA:

16 years of age or older
Diagnosed disability and/or perceived barrier to employment
Able to perform activities of daily living
Not harmful to self or others
Completed Health Assessment Questionnaire
Able to benefit from the Program
Funding for the program, if applicable

Now, simply answer the following questions and submit the form. Thank you!

Basic Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Main Phone*

Cell Phone

Email

Date of Birth*

Gender*

Male
Female
Transgender

Please List Any Other Names You Have Been Known By

Please List Any Other States You Have Resided In

Veteran?*

Yes
No

Enlisted Years

Branch Of Service

Hidden

Metro*

Program Applying For*

Day Services
Supported Employment
Retail Skills Training
Warehouse Skills Training

Ethnicity*

Asian/Pacific Islander
Black, African American
Hispanic
Native American
White

Do you have a diagnosed disability?*

Yes
No

Axis I Diagnosis*

Please Include ICD-10 Code With Diagnosis

Axis II Diagnosis

Please Include ICD-10 Code With Diagnosis

Case Manager's Name

Case Manager's Agency

Case Manager's Phone

Case Manager's Email

Case Manager's Address

Street Address Address Line 2 City State ZIP Code

Are you your own legal guardian?*

Yes, I am my own legal guardian
No, my parent or guardian makes legal decisions for me

Guardian's Name*

Guardian's Phone*

Guardian's Address*

Street Address Address Line 2 City State ZIP Code

GOODWILL OF CENTRAL IOWA

Intake & Admission

Step 1 of 2

ADMISSION CRITERIA:

Basic Information