ETA 9214 Social Intake Form

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA FORM 9214 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Social Intake Form

Instructions: Counselors must complete this form in an interview format within the student’s first 48 hours of enrollment per PRH Chapter 2.4, R2 (a). After completion, this form must be sent to the Health and Wellness Center as soon as possible and reviewed within 1 week of the student’s arrival. This form contains Protected Health Information (PHI) and sensitive information protected by federal confidentiality rules (42 CRF Part 2) and must be stored in a locked cabinet in a locked office with limited access per PRH Appendix 202.

Demographic Information
Legal Name:		Student ID:
Email Address:		Status:	☐ Resident ☐ Non-Resident
Address: (Include City, State, Zip Code)
Cell Phone Number:
Date of Birth:
DOE:
Age:

Family Of Origin
Mother/Guardian			Father/Guardian
Name:			Name:
Address:			Address:
City:			City:
State:			State:
Zip Code:			Zip Code:
Phone Number:			Phone Number
Who raised you?
Who have you lived with for the past year?
How long have you lived there?
Do you feel safe living there?			☐ Yes ☐ No
If you are a minor, do you live with your parent(s)/guardian(s)?			☐ Yes ☐ No If no, why?
Do you have any siblings?			☐ Yes ☐ No If yes, how many:
Describe your relationship with the following people (excellent, good, fair, poor, none):
Mother/guardian:
Father/guardian:
Siblings:
Significant other/spouse:
Friends
Others (teachers, bosses, etc.):

Children
Do you have any children?	☐ Yes ☐ No (skip to next section) If yes, how many:
Provide children’s name(s) and age(s):
Name:	Age:
Name:	Age:
Name:	Age:
Has the Job Corps child allotment been explained to you?	☐ Yes ☐ No
Who is providing care for your child(ren) while you are at Job Corps?

Caseworker
Do you have a caseworker?		☐ Yes ☐ No
If yes, caseworker’s name:
Phone Number

Legal Issues
Have you ever been in trouble with the police?	☐ Yes ☐ No If yes, what happened? When did this happen (year)?
Are you presently awaiting charges, court, or sentencing?	☐ Yes ☐ No If yes, for what?
Are you currently on probation?	☐ Yes ☐ No If yes, provide the probation officer’s information: Name: Phone Number: Address (City, State, Zip Code):

Education And Military Background
Did you receive any special education or resource classes?	☐ Yes ☐ No If yes, in what areas? When did you receive services?
Did you complete high school?	☐ Yes ☐ No If no, why did you stop? When (year)?
Were you ever suspended or expelled?	☐ Yes ☐ No If yes, how many times were you suspended or expelled? What were the reason(s)?
Have you ever been in the military?	☐ Yes ☐ No If yes, why did you leave the military?

Personal And Career Aspirations
What are your career goals after you finish Job Corps?
What are your personal goals after you finish Job Corps?

Wellness Support Job Corps wants to support you with your career goals. Often, personal issues can interfere with your career goals. Job Corps offers a full program of support, including basic health services. Information in the sections below will be confidential and shared only with staff/agencies with a need to know as required by Job Corps or state laws.
Have you ever been to see a psychologist, therapist, psychiatrist, counselor, or social worker, or been in any kind of counseling before?			☐ Yes ☐ No If yes, for what reason? When (years)? How many times? Approximate date of last appointment:
Have you ever taken any medicine to help you with feeling sad, worrying, having trouble paying attention, or for behavior?			☐ Yes ☐ No If yes, when (year)? What was the medicine? Who gave it to you? How long did you take it?
Have you ever had an emergency room or hospital visit for a mental health or substance use problem?			☐ Yes ☐ No If yes, for If yes, when (year)? what reason?
EMOTIONAL WELLNESS—Part 1
Over the PAST 2 WEEKS have you experienced any of the following? (Check all that apply)
☐ Little interest or pleasure in doing things ☐ Feeling down, depressed, irritable, or hopeless ☐ Anger issues (punching the wall or breaking things, screaming) ☐ Attention or concentration issues (have ADD/ADHD, can’t sit still, can’t complete tasks, hard time focusing)		☐ Grief (feeling sad about the death of a loved one, breakup or relationship loss) ☐ Feeling nervous, anxious, or on edge ☐ Not being able to stop or control worrying ☐ Sleep problems (such as nightmares, having trouble falling or staying asleep)				☐ Eating or weight concerns (making yourself throw up, stop eating to lose weight) ☐ Feel upset or worried about sexual behavior, thoughts, or feelings ☐ Relationship stress ☐ Parenting stress (with child’s other parent or stress with parenting)
Emotional Wellness—Part 2 (If student endorses any item in this section, Counselor must check an action response in Part A: Counselor Next Steps (at end of SIF).
Over the PAST 2 WEEKS have you experienced any of the following? (Check all that apply)
☐ Self-harm behaviors (e.g., cutting, burning, scratching) ☐ Wished you were dead or wished you could go to sleep and not wake up ☐ Felt that you or your family would be better off if you were dead ☐ Have had any thoughts of killing yourself ☐ Have a plan to hurt or kill yourself ☐ Have access to a way to hurt or kill yourself				☐ Thoughts of hurting or killing someone ☐ Have a plan to hurt or kill someone ☐ Hurting people or animals ☐ Hearing voices when no one else is around ☐ Seeing things that other people around you do not see ☐ Thinking other people are watching you or out to get you
Emotional Wellness—Part 3
Have you EVER experienced and of the following? (Check all that apply)
☐ Bullying ☐ Verbal abuse ☐ Sexual abuse ☐ Physical abuse	☐ A traumatic event such as seeing or experiencing violence, a car accident, natural disaster (e.g., hurricane, flood, fires) ☐ Hear or see things that other people do not				☐ Self-harm behaviors (such as cutting, burning, scratching) ☐ Thoughts of hurting or killing yourself or others ☐ Trying to hurt or kill yourself or others
Are any of the items checked in this section still going on? ☐ Yes ☐ No If yes, explain:

Alcohol And Drugs (Questions in the Alcohol and Drugs section are from the CRAFFT (V2.1) of The Center for Adolescent Substance Use Research (2018) and located at: https://crafft.org/)
During the past 12 months have you:
1. Drank more than a few sips of beer, wine, or any drink containing alcohol?	☐ Yes ☐ No
2. Used marijuana (cannabis, weed, oil, wax, or hash) by smoking, vaping, dabbing, or in edibles, or used synthetic marijuana (like K2 or Spice)?	☐ Yes ☐ No
3. Used anything else to get high (other illegal drugs, pills, prescription or over-the-counter medications, and things that you sniff, huff, vape, or inject)?	☐ Yes ☐ No
If the student answered NO to all three questions above, ask Question 4 only. If the student answered YES to any of the questions above, ask Questions 4 through 9.
4. Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?	☐ Yes ☐ No
5. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?	☐ Yes ☐ No
6. Do you ever use alcohol/drugs while you are by yourself, ALONE?	☐ Yes ☐ No
7. Do you ever FORGET things you did while using alcohol or drugs?	☐ Yes ☐ No
8. Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?	☐ Yes ☐ No
9. Have you gotten into TROUBLE while you were using alcohol or drugs?	☐ Yes ☐ No
10. In the past year have you used any type of product containing nicotine, such as cigarettes or vapes?	☐ Yes ☐ No

Protective Factors
When you are upset, what helps you relax?
What are your favorite things to do in your free time?
Do you participate in any religious/faith based/cultural/spiritual practices?	☐ Yes ☐ No If yes, describe.
What are some of your strengths/talents?

I have answered these questions honestly. I understand that my answers will be shared with Health and Wellness staff.
SIGNATURE:	DATE:

Part A: Counselor Next Steps (To be completed by the Counselor. Check all that apply.)
☐		The student endorsed an item in EMOTIONAL WELLNESS—Part 2 and I immediately notified Counseling Manager or designee.
☐		I have an immediate concern regarding response(s) and I notified Counseling Manager or designee.
☐		Counselor will check-in with student _________ (specify frequency) to provide additional support regarding ___________(specify).
☐		Refer to on-center group run by Counseling Department or another department (e.g., Anger Management, Healthy Relationships) List specific group(s):
☐		Refer student to Recreation/HEALS Coordinator
☐		Refer to Disability Coordinator
☐		Other (specify):
SIGNATURE:			DATE:
Part B: Counseling Manager Next Steps (To be completed by the Counseling Manager. Check all that apply.)
☐	I notified Health and Wellness because the student endorsed answers that required immediate assessment or there are concerns. Name of staff person notified:
☐	Forwarded SIF to Health and Wellness.
Reviewed by Counseling Manager
SIGNATURE:				DATE:
Part C: Center Mental Health Consultant (CMHC) Next Steps (To be completed by the CMHC within 1 week if indicated)
☐	This box is only required for centers where the CMHC does not review all SIFs per center policy: CMHC review is not required because in section 8, the student does not report a mental health history or endorse any answers in the Emotional Wellness sections. SIF was not forwarded to CMHC.
Health and Wellness Staff person making this determination
SIGNATURE:				DATE:
☐	Reviewed SIF
☐	Schedule mental health intake appointment
☐	Discuss student at Case Management meeting
☐	Refer to Disability Coordinator
☐	Other:
☐	No follow-up is needed currently
Reviewed by Center Mental Health Consultant
SIGNATURE:				DATE:
Part D: TEAP Specialist Next Steps (To be completed by the TEAP Specialist within 1 week of student’s arrival)
☐	Reviewed CRAFFT. The number of items endorsed in items 4 through 9 is _______ out of 6. (CRAFFT score)
☐	CRAFFT score is 2 or more: Administer formalized assessment measure (required)
☐	CRAFFT score is less than 2: No formalized assessment measure required
☐	Schedule TEAP Appointment
☐	Meet with student to recommend attendance at Relapse Prevention group
☐	Other:
☐	No follow-up is needed at this time.
Reviewed by TEAP Specialist
SIGNATURE:				DATE:

Part E: Recordkeeping
☐	Health and Wellness returned signed copy of SIF to Counseling Manager
☐	Original filed in Student Health Record

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

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