JFCS Special Connections Application Form

Name:*

Nickname/preferred name (optional):

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Parent's Email*

Parent's Phone*

Date of birth:*

Age:*

Intellectual/developmental disability:*

Conservatorship status:*

Yes
No

If conserved, in what areas?*

Gender: How do you identify? (check all that apply):*

Female
Male
Trans man
Trans woman
Non-binary
Not sure
Other

Other gender description (optional)

Personal pronouns (optional)

What is your Sexual Orientation/attraction? Who do you want to have a relationship with? (Select one)*

Heterosexual/straight- seeking relationship with person of different gender
Gay–seeking relationship with same gender
Lesbian- woman seeking relationship with a woman
Bisexual- seeking relationship with men or women
Queer- seeking relationship across multiple different gender identities (male, female, trans, queer, etc.)
Questioning/Curious/Unsure

Describe three of your strengths:

First Strength:*

Second Strength:*

Third Strength:*

What is one thing you struggle with/that is hard for you?

First Challenge:*

Second Challenge:*

Third Challenge:*

About You

There are no right or wrong answers. We just want to get to know you a little.

When I meet new people, I feel ... (Select one)*

Other—please explain:*

How do you enjoy spending your free time?*

What are your special interests or hobbies?*

Why do you want to participate in Special Connections?*

What do you want special connections to help you learn and practice regarding dating and relationships?*

Other area I want Special Connections help me learn or practice:*

Anything else you hope will happen from participating in Special Connections?

How many dates (online, face-to-face, or speed dating events) have you been on in the past 3 years? (Select one)*

I have never been on a date
1 – 3
4 — 8
More than 8

My previous dating experience was positive.*

Not at all true
A little true
Pretty much true
Definitely true

I feel ready to date: (Select one)*

Not at all true
A little true
Pretty much true
Definitely true

I feel confident about dating: (Select one)*

Not at all true
A little true
Pretty much true
Definitely true

When I think about the idea of being in a romantic relationship, I feel … (Select all that apply)*

How much help did you have in filling out this application? (Select one)*

No help, completed independently
A little help with the reading/writing/typing, words are all my own
Someone helped me to answer most of the questions
Someone else completed the application for me

How did you hear about the program?*

Name

This field is for validation purposes and should be left unchanged.

JFCS Special Connections Application Form

Describe three of your strengths:

What is one thing you struggle with/that is hard for you?

About You

Survey Response Form

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