Client Questionnaire Page 2
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4List any professional or occupational licenses you have (e.g. cab license, plumbing license):
________________________________________________________________________
________________________________________________________________________
Have you had to pass a background check to get a job: yes ; no
If yes, explain: ___________________________________________________________
________________________________________________________________________
Have you, or do you intend to, work in:
schools or school services (e.g. teacher, school janitor, school cafeteria, etc.)
healthcare
a place that cares for the elderly or persons with disabilities (adult foster home, nursing home,
etc.)
private security/security guard
airline transportation
transportation
childcare
government employment
military
tribal government or Native American casinos
General Contractor
Criminal Justice/Law Enforcement
If you work in schools, long-term care, transportation, childcare, and certain other fields, you may
be required to report your arrest or any conviction to your employer.
Have you reported your arrest to your employer: yes ; no
HOUSING
If you are convicted of a criminal offense, depending on your conviction, you can be evicted. If you
live in subsidized housing or have a Section 8 voucher, you can lose that as well. The members of
your household can also lose their housing. You should talk to a legal aid attorney.
If you rent, do you have a lease: yes ; no
If yes, when is your lease up: _______________________
Has your landlord threatened to evict you: yes ; no
Do you live in subsidized rental housing or have a Section 8 voucher: yes ; no
If you live in subsidized housing or have a Section 8 voucher, list every person who lives with you,
including their name, age, and relationship to you:
Name
Age
Relationship to You
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Parent category: Life