Preliminary Intake Application (W.I.N.)

WIN Intake Form

MM slash DD slash YYYY


Do you have these documents?

SS Card
Birth Certificate


Do you need a SEPTA Key Card to get to and from the ICJ offices at 1207 Chestnut St?
Do you have Zoom and feel comfortable using it for remote communication?

Work Experience

Please list the most recent or longest-lasting jobs that you’ve had, including volunteer positions:


Please list character references you have, including your case manager if applicable:

5-Year Plan

I have to say, ICJ is very good at what they do, so I want to thank them, and I’m proud of myself for doing everything I can to get on my feet.

Victor Rodriguez

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