Intake Form (Updated) — Preview First, let's get some contact info: Next, tell us about yourself: *Date of birth: *Age: *Are you currently using public assistant? (Please select all that apply.) NoneCash assistanceChildcare assistanceFood stampsHousingMedicaidSSI or RSIDUnemployment *Highest Level of Education Completed Less than 9th gradeSome High SchoolHigh School DiplomaGED / HiSETTechnical or Vocational DegreeSome College2-year Associate's degree4-year Bachelor's degreeSome Graduate SchoolGraduate, doctoral or terminal degree *In order to help us measure our diversity practices, please select the ethnicity group you most closely identify with. AsianBlack/African AmericanHispanic/LatinaMulti-RacialNative AmericanWhite/CaucasianOtherPrefer not to say *Number of dependents under the age of 18 living at home with you *Number of children total (even those outside your home) *Current marital status SingleMarriedDivorcedSeparatedWidowed *Are you a single parent? YesNo *Are you a US veteran or active duty military? NoI'm an immediate family member of a US veteranI'm the spouse of an active duty military memberYes, I'm dischargedYes, I'm activeYes, I'm retiredYes, I'm a reservist *US citizenship status US Born CitizenUS Naturalized CitizenImmigrantRefugeePrefer not to answer *Have you ever been incarcerated? YesNo Finally, tell us about your current situation: *What brings you to Dress for Success Quad Cities? I'm unemployed and currently job searchingI have an upcoming job interviewI have accepted a new full/part time job that I start soonI'm employed full-time but am thinking about going back on the job marketI'm employed part-time and looking for a full-time jobI'm employed but want to invest in my professional developmentI'm employed and want to connect and network with othersOther If Other, please explain If you have an interview scheduled, what is the date of your interview? (If this does not apply, please skip this.) If you have an interview scheduled, what company are you interviewing with? (If this does not apply, please skip this.) If you have an interview scheduled, what position/industry you are interviewing for? (If this does not apply, please skip this.) *Have you been offered a job? YesNo Where is the job / what is the position? (If this does not apply, please skip this.) *Does it have specific clothing requirements? YesNo What is your start date? (If this does not apply, please skip this.) *Do you currently make less than $15,960 annually (the US poverty level)? YesNo *Do you currently make less than than $32,749 annually (Scott County's living wage level)? YesNo *Do you currently make less than $58,380 (regional average annual salary level)? YesNo *How did you hear about Dress for Success Quad Cities? Google searchSocial media (Facebook, Instagram, LinkedIn, etc.)Referred by another agencyA friend or family memberA fundraising event or saleA volunteer organizationOther *If you were referred to us by another agency, please select the organization that referred you: (If you were not referred by another organization, please select None.) American Job CenterArc of the Quad Cities AreaArgrow's HouseBettendorf Police DepartmentBettendorf Schools Outreach ProgramBlack Hawk CollegeBloom TherapyCenter For Alcohol & Drug Services (CADS)Child Care Resource and Referral of Southeast IowaChildren & Families in IowaChristian CareChurches UnitedCommunity Action of Eastern IowaCommunity Home Partners (RIHA)Congregation of the Humility of MaryDavenport Public LibraryDeLaCerda HouseEastern Iowa Community College (EICC)Edwards UCCFamily ResourcesFirst Baptist Church of CordovaGenesis Bright BeginningsGilda's ClubGoodwill of the HeartlandHumble DwellingsHumility Homes & ServicesIllinois Army National GuardIllinois Department of Employment Security (IDES)Iowa Vocational Rehab Services (IVRS)IowaWORKS of Eastern IowaISU Scott County ExtensionLead(h)erLutheran Services of IowaMidwest Technical Institute (MTI)Milan Presbyterian ChurchMoline Housing AuthorityNarratives QCNational Able NetworkOrion Technical CollegePregnancy ResourcesProject NOWPurdue University GlobalQC Alliance for Immigrants & Refugees (QCAIR)Quad Cities Veterans Outreach CenterRobert Young Community Mental Health CenterRock Island County Council on Addictions (RICCA)Rock Island Public LibraryRock Island TownshipSafe Families for ChildrenSafer FoundationSalvation Army Quad CitiesSedona StaffingThe Abby CenterThe Center for Youth & Family SolutionsThe Clothing Center At Minnie's MaisonThe ProjectThird Missionary Baptist ChurchTransitions Mental Health ServicesTrinity College of Nursing & Health SciencesTwo Rivers YMCAUnited African OrganizationUnited Way Quad CitiesVera French Community Mental Health CenterWomen's Choice CenterWorld ReliefNone of these If the organization you were referred by was not listed above, please enter the name of the organization: Were you referred by a specific person at the organization? If so, please let us know who: *Which of the following programs and services are you interested in? (Please select all that apply.) Networking Opportunities (opportunities to connect and network with other QC women)Financial Literacy ProgrammingJob Fairs and employer eventsCareer & Professional Development WorkshopsGuest Speakers & WorkshopsPersonal Development Workshops (e.g., health/wellness, mindset, leadership, resources, etc.)Social Opportunities (opportunities to socialize with other QC women)Access to Free and Low-Cost Professional Clothing & Attire for an InterviewAccess to Free and Low-Cost Professional Clothing & Attire for New EmploymentResume creationResume review or editInterview preparation assistance *I understand that if I do not call to cancel or show up for a scheduled appointment with Dress for Success Quad Cities, then it may impact my ability to use the StyleHER or Career Coaching services. Please note: as long as you notify us prior to your scheduled appointment, we can reschedule up to 2 times. *I understand that by utilizing the programs and services of Dress for Success Quad Cities that I agree to allow my likeness and statements to be captured and used for marketing purposes. *I understand that appointments are generally for the scheduled client only. If I need accommodation or a support person, I will contact Dress for Success Quad Cities before my appointment. I would like to receive email notifications about upcoming workshops and events. Style Questionnaire (Updated) — Preview Personal Information *Age What is the company/industry of the job you want to be styled for? Your Sizing & Shape Please answer the following questions, so that we can get an idea of your size and shape. If you are in-between two sizes, please round up. We will not accept any returns or exchanges on clothing. All of your data remains private. *What is your general shape? Hourglass (full bust and hips, narrow waist)Full Hourglass (fuller bust, bigger thighs, rounded bottom and hips, smaller waist)Apple (rounder shoulders, flattish bottom, average to full bust, fullness around the middle)Pear (full hips or thighs, a defined waist, shoulders narrower than hips, smaller top half)Inverted Triangle (full bust, narrow waist and hips)Lean Column (narrow shoulders, flat chest or small bust, small or non-defined waist, narrow hips and flat bottom)Rectangle (similar shoulders, waist, and hips) What is your bra size? *What is your top/blouse size? If you aren't sure, please measure your bust size. 0 (XS) - Bust Size 322 (XS) - Bust Size 334 (S) - Bust Size 346 (S) - Bust Size 358 (M) - Bust Size 3610 (M) - Bust Size 3712 (L) - Bust Size 38 1/214 (L) - Bust Size 4016 (XL) - Bust Size 43 1/218 (XL) - Bust Size 45 1/22X (18-20) - Bust Size 46-483X (22-24) - Bust Size 50-524X (26-28) - Bust Size 54-565X (30-32) - Bust Size 58-60 *What is your pant size? If you're not sure, please measure your waist and hips to help you determine the appropriate size. NOTE: - If you regularly shop plus size clothing the "women's" (W) sizing indicates plus sizing. 0 (Waist 24 inches, Hips 34.5 inches)2 (Waist 25 inches, Hips 35.5 inches)4 (Waist 26 inches, Hips 36.5 inches)6 (Waist 27 inches, Hips 37.5 inches)8 (Waist 28 inches, Hips 38.5 inches)10 (Waist 29 inches, Hips 39.5 inches)12 (Waist 30.5 inches, Hips 41 inches)14 (Waist 32 inches, Hips 42.5 inches)16 (Waist 33.5 inches, Hips 44 inches)18 (Waist 35 inches, Hips 45.5 inches)16W (Waist 37 inches, Hips 46 inches)18W (Waist 39 inches, Hips 48 inches)20W (Waist 41 inches, Hips 50 inches)22W (Waist 43 inches, Hips 52 inches)24W (Waist 45 inches, Hips 54 inches)26W (Waist 47 inches, Hips 56 inches)28W (Waist 49 inches, Hips 58 inches)30W (Waist 51 inches, Hips 60 inches) Do you know what your inseam length is (in inches)? If you are able to, you can measure your "inside leg" length (see previous photo) to determine your inseam length. *When you purchase pants and/or tops, do you regularly shop in the standard size section OR in the plus size/women's section? Standard Section or StorePlus Section/Women's Section or Store *Do you regularly purchase "Tall" or "Petite" pants? Yes, I almost always purchase 'Petite' pantsYes, I almost always purchase 'Tall' pantsNo, I purchase standard length pants *How tall are you? *What is your Dress Size? 024681012141618202224 *Which dress lengths are you comfortable wearing (check ALL that apply)? Above the KneeAt the Knee or Below the KneeMidi/Mid-CalfMaxi/AnkleNo preference *What is your shoe size? 55.566.577.588.599.51010.51111.51212.513 What type of heel/shoe works best for you (check ALL that apply)? Flats/Loafers (no heel)Wedge/Wedge-Like HeelsShort Heels (Kitten Heels/Short Stiletto Heels)Heels/StilettosBoots What toe shape do you prefer (check ALL that apply)? RoundSquarePointed What shoe width do you prefer (check ALL that apply)? NarrowWide What type of sleeve length are you comfortable wearing in tops, blouses, or dresses (check ALL that apply)? SleevelessShort Sleeves3/4 Length Sleeve (hits at or just below the elbow)Long SleevesI'm comfortable wearing sleeveless tops, but I would prefer to have a cardigan to wear over themNo Preference What type of necklines are you comfortable wearing in tops, blouses, or dresses (check ALL that apply)? Collared, Button Up (typically long-sleeved)ScoopU-NeckV-NeckSquareCowlSweetheartKeyholeNo Preference Your Sizing & Shape Answering the below questions will help us get a sense of your style. While we cannot guarantee an outfit that meets your desired style preferences, we do our very best to take your preferences into account. All of your data remains private. *Which items would you like your Image Coach to pull for you (check all that apply)? Pants + TopDressesSkirtsSuit Jackets *Do you have a preference for how tops fit (check all that apply)? I like a tighter fitI like tops to be fitted, but not clingyI like a loose, flowy fitI have no preference *Do you have a preference for how your pants fit (check all that apply)? SkinnyStraightBoot cutTrouserWide leg *How would you describe your personal style (choose up to 3)? BoldBrightBlack & WhiteClassicChicCleanColorfulConservativeDramaticFeminineLayeredMinimalistNeutralPlayfulPreppyPracticalSophisticatedTraditionalUniqueUnderstated *Are there any colors you would never wear? *Are there any colors you love? *What kind of prints and/or details do you prefer? Animal printsFloral printsAbstract/Geo printsRufflesEmbellishments - buttons, fancy stitching, laceEmbellishments - sequins, appliques, and sparklesN/A *Are there any fabrics you would like us to avoid? Any additional style notes? For example, you might say something like: I have a larger chest and really need my top/blouse material to have a little bit of stretch or give in it. You could also say something like: I have a very athletic frame with larger calves and thighs. Career Success Center Assessment (Updated) — Preview To help us match you with a career coach who can best support you, please complete this assessment. Your answers will help us understand where you are in your career journey, your goals, and any challenges you may be facing. Once completed, our team will review your response and connect you with an appropriate career coach. Current Employment Situation *What is your current employment status? Employed full-timeEmployed part-timeSelf-employedTemporarily employedUnemployedStudentOther *What is your current job title/position? If you are currently unemployed, what was your most recent job title/position? *What type of job is/was this? Full-time, PermanentFull-time, TemporaryPart-time, PermanentPart-time, TemporaryContractorAs NeededNA *When do you work? If you are not currently working, what shift would you like to work? (Please select all that apply.) 1st Shift (Days)2nd Shift (Evenings)3rd Shift (Overnights)WeekendsOther If Other, please specify. *How long have you been at this job? If you are currently unemployed, how long were you at your most recent job? 0 - 3 Months6 - 12 Months1 - 2 Years3+ YearsNA *What is your approximate annual income from employment? Under $15,000$15,000-$29,999$30,000-$49,999$50,000-$74,999$75,999-$99,999Over $100,000 *If you are currently employed and seeking a different job, what is motivating you to make a change? If this question does not apply to you, please type NA. *If you are currently unemployed, how long have you been out of work? 0 - 3 Months3 - 6 Months6 - 12 Months1+ YearNot Applicable - I am currently employed *Are there any challenges or barriers that may affect your ability to find or maintain employment? (Please select all that apply.) No reliable childcareNo reliable transportationCriminal backgroundUnstable housingA lack of understanding about workplace expectationsLanguage/communicationEducation or trainingDisability/accessibility needsNo, I do not face any of these challengesOther If Other, please specify. *How many jobs have you had in the last 2 years? 0-12-34 or more Career Goals The following questions help us understand your career interests and goals so we can match you with a career coach who can help you the best! What industry are you currently working in (or have past experience working in)? (Please select all that apply.) HealthcareSocial ServicesEducational ServicesConstructionManufacturing & WarehouseBusiness Administration & ManagementFood Service & HospitalityRetailFinanceInformation TechnologyCustomer ServiceGovernment/Public ServicesLegal & AccountingCommunications, Graphic Design & MediaBeauty & WellnessSecurity & Law EnforcementAgriculture, Forestry & ParksOther If Other, please specify. What industry do you want to work in? (Please select all that apply.) HealthcareSocial ServicesEducational ServicesConstructionManufacturing & WarehouseBusiness Administration & ManagementFood Service & HospitalityRetailFinanceInformation TechnologyCustomer ServiceGovernment/Public ServicesLegal & AccountingCommunications, Graphic Design & MediaBeauty & WellnessSecurity & Law EnforcementAgriculture, Forestry & ParksOther If Other, please specify. What types of jobs or positions are you interested in pursuing? Where are you at in your Career Journey? (Please select all that apply.) I don't even know where to begin, I'm not sure what types of jobs I can apply for with my skills and/or I'm not sure about what industry I want to work in.I'm looking for jobs, but I need help learning about the best places and best ways to search for jobsI know what types of jobs I want to apply for, but I don't have a strong working resume, I need resume helpI have a general resume, but I've been sending it out and haven't gotten any responses, I need help!I have a general resume, but want to learn how to improve it by tailoring it for the jobs I am applying forI'm concerned that my social media and/or lack of online presence may be affecting my job searchI need help with cover letterI've got resumes ready to go, but I'm really worried about interviewing, I could use some practice and tipsI've been interviewing, and so far--I haven't gotten any job offersI've never negotiated my salary/pay before, and I want to learn how to do that so that I'm preparedI'm ready to take my social/online presence to the next level because I think it will help me find and land a jobI'm interested in any and all resources and best practices that can help me on my career journeyI want to learn new skills and I'd like help in determining which skills are most marketableI'm not currently looking for a job, but I want to stay in the loop regarding best job search strategiesOther If Other, please specify. *How motivated do you currently feel to work toward your career goals in your career or job search? What motivates you? *How much stress are you currently experiencing related to career or job search? *What are the main challenges affecting your career or job search? *Thinking 1 year ahead, what would you like your career or employment situation to look like? *What are the three most important career goals you would like to achieve within the next three months? *What would you like to accomplish through career coaching? *What is your availability? Tell us what days/times you are most available to do a 1:1 coaching session. *Would you like your coaching sessions to take place in person (at our Davenport location) or take place virtually (via Zoom)? VirtualIn PersonI can do virtual OR in person Your resume is an important piece of your career journey, and helps our coaches understand where you are at and the types of jobs you are interested in. Please upload a copy of your most current resume. Criminal Background If you have a criminal background, please answer the following questions; so that our career coaches can best assist you. If you do not have a criminal background, you may skip this section. Are you currently incarcerated? Yes No Release date: What type of charge(s) do you have? Felony Class AFelony Class BFelony Class CFelony Class DMisdemeanor Class AMisdemeanor Class BMisdemeanor Class CI am not sure what charges I haveI have had my felony or misdemeanor sealed and expungedOther If Other, please specify. How old is your charge? I was convicted within the past yearI was convicted between 1-3 years agoI was convicted between 4-7 years agoI was convicted between 8-10 years agoIt has been over 10 years since I was convicted What do you know about sealing and/or expunging your record? I don't know how, but I would like helpI have tried and was deniedI know I cannot with my type of chargeI have never thought about itOther If Other, please specify.
