Transitioning Military & Veteran Workforce Development Intake

Page 1 - General Information

Select the workshop location you would like to attend

Select a program

Please select the preferred industry you are interested in

Is there a company that you are interested in working for?

Personal Information

Last 4 Digits of Social Security #

First Name

Last Name

Current Street Address

City

State/Province/Region

Zip Code

Are you moving after your military service?

Yes

Preferred Street Address

Preferred City

Preferred State

Preferred Zip Code

Phone Number

Alternate Phone

Email Address

non-military email address

Date of Birth

Age

Gender

Ethnicity

Highest Level of Education

Area of Study

Living Situation

Are you Homeless?

Yes

Are you at Risk of Homelessness?

Yes

Are you at living in subsidized housing?

Yes

Family Information

What is your Marital Status

Family Size

Annualized Family Income

Total household Gross wages and salaries before deductions.

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Emergency Contact Email Address

Referral Information

Referral Name

Referral Company

Referral Company (Other)

Referral Phone Number

Referral Email Address

Page 3 - Assessment(s)

Psychosocial Risk Factors

Select “Yes” if the following has significantly affected your emotional well being, safety, health, or daily functioning within the past 30 days. Otherwise, select “No.”

	Yes	No
Mental health challenges
Substance use challenges
Serious chronic health conditions
Chronic pain
Traumatic brain injury
Prolonged stress
Stressful life events
Unemployment
Homelessness
Recent loss
Legal challenges
Financial challenges

Select “Yes” if any of the following has occurred at any point in your life.

Page 4 - Workshop Pre-Survey

The following questions are part of a pre-REBOOT workshop survey. Your responses will have no bearing on your application to attend a workshop. We collect this information to evaluate the REBOOT workshop and the data can help us obtain more funding so that additional veterans can attend. Please answer all questions.

For each statement below, please read carefully and indicate how much confidence you have that you could accomplish each of these tasks or beliefs by marking your answer according to the following 5-point scale.

1 = No Confidence

2 = Very Little Confidence

3 = Moderate Confidence

4 = Confidence

5 = Complete Confidence

1. Make a career decision and then not worry about whether it was right or wrong.

2. Find information about companies who employ people with my background and skill set.

3. Prepare a good resume.

4. Change occupations if you are not satisfied with the one you enter.

5. Choose a career in which most workers are the opposite sex.

6. Identify some reasonable career alternatives if you are unable to get your first choice.

7. Figure out what you are and are not ready to sacrifice to achieve your career goals.

8. Determine what your ideal job would be.

9. Describe the job duties of the career you would like to pursue.

10. Successfully manage the job interview process.

11. Find information about occupations you are interested in.

12. Find out the employment trends for an occupation.

13. Move to another city to get the kind of job you really would like.

14. Decide what you value most in an occupation.

15. Persistently work at your career goal even when you get frustrated.

16. Choose a career that will fit your preferred lifestyle.

17. Identify employers, firms, institutions relevant to your career possibilities.

18. Resist attempts of family or friends to push you into a career you believe is beyond your abilities.

19. Determine the steps you need to take to successfully complete your chosen career goal.

20. List several occupations in which you are interested.

21. Choose a career that will suit your abilities.

22. Choose a career that will suit your interests.

23. Get involved in a work experience relevant to your future goals.

24. Find out about the average yearly earnings of people in an occupation.

25. Talk with a person already employed in the field you are interested in.

26. I can communicate my strengths to potential employers

27. Choose a career that your family does not approve of

28. Go back to school to get a degree after being out of the military

29. Find accurate information about educational programs.

30. Choose the area of study you want irrelevant of the competitiveness of that field.

31. Change area of study/vocational training if you did not like your first choice.

32. Have the ability to successfully take challenging courses.

33. Select one major/vocational training from a list of potential majors/vocational training you are considering.

34. Apply again to schools after being rejected the first time.

35. List several majors/vocational trainings in which you are interested

36. Determine the academic subject you have the most ability in.

37. Attend college or professional school to achieve your career goals.

38. Make a plan of your goals after the military.

39. Accurately assess your abilities.

40. Define the type of lifestyle you would like to live.

41. Feel prepared to achieve my goals outside of the military.

42. Have a clear vision of what my future could be outside of the military.

43. Find a job outside of the military.

Additional Questions

List your 5 greatest fears in your transition from military to civilian life:

List the 5 greatest challenges you face in your transition from military to civilian life:

List your 5 greatest strengths:

The REBOOT Workshop is free. However, if there were a charge, how would you choose to pay?

Page 5 - Consent to Release

Services Provided

I give the National Transition Services, Inc. and their partners approved personnel permission to followup with recruiters on my behalf regarding resumes, interviews, and hiring.

I Agree to Services Provided

Follow Up Agreement

Reboot conducts follow up surveys after program completion to determine program effectiveness in achieving our goals. I agree to maintain contact and provide NVTSI (REBOOT) with follow-up information after program completion. This data will be used for internal reporting purposes only

I Agree Follow Up

Newsletter Consent

By signing this form I agree to be automatically subscribed to the newsletter and receive updates and request for more information.

I Agree to Newletter

Photograph and Video Consent to Release

I hereby grant the National Veterans Transition Services, Inc. (NVTSI) permission to use my likeness in a photograph or video in any and all of its publications, including web site entries, without payment or consideration.

I understand and agree that these materials will become the property of the National Veterans Transition Services, Inc. and will not be returned.

I hereby irrevocably authorize the National Veterans Transition Services, Inc. to edit, alter, exhibit, publish or distribute this photo for the purposes of publicizing the National Veterans Transition Services, Inc.’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive my right to royalties or any other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge the National Veterans Transition Services, Inc. from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am 21 years of age and am competent to contract in my own name. I have read this release and I fully understand the contents, meaning, and impact of this release.

I Agree to Photo & Video Consent

	Yes	No
Previous suicide attempts
Family history of suicide
History of abuse, neglect, or trauma