Self Assessment DHS 7823 1/09
[pic] |My Self Assessment | |
|Name (First, Last, MI) |Date of Birth |Social Security Number |
| | - - | - - |
|Street Address/City/State/Zip Code |Phone Number | Cell |
| | |Home |
| | |Message |
| |( ) | |
|Signature | |Date |
|1. My Family |
|1. How many people are living in your household? | |How many are children? | |
|2. What school(s) do your children attend? |
|3. How are your children doing in school? (academically and socially) |
|4. Check which of the following describes your household. |
|Two Parent Single Parent Teen Parent |
|5. Are you responsible for caring for a disabled person on a daily basis? Yes No |
|6. Who in your household would encourage your working? |
|7. Who in your household would discourage your working? |
|8. Other than people in your household, what other people would encourage your working? |
|9. What help do you think you could get from family and friends? |
|2. My Family’s Health |
|Do you have any medical problems? Yes No |
| |
|If yes, are you under a doctor’s care for this problem? Yes No |
| |
|3. |
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|( ) |
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|Doctor’s Name |
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|Phone Number |
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|Do you have problems with any of the following instructions? (Check all that apply) |
| lifting | standing | walking | bending |
| sitting | breathing | seeing | hearing |
| reading | writing | paying attention | concentrating |
| following instructions | staying awake | other: | other: |
| | | |
|Would any of these problems affect your working? Yes No |
| If yes, which ones would be a problem? |
|Does anyone in your household have any medical problems? Yes No |
| If yes, what are the problems? |
|7. Would any of these problems affect your working? Yes No |
| If yes, which ones would be a problem? |
|3. My Education |
|Check highest grade completed: |
|1 2 3 4 5 6 7 8 9 10 11 12 13 14 16+ |
| |
|Do you have a high school diploma? Yes No |
| |
|Do you have a GED? Yes No |
|What other schooling or training have you had since high school? (Check all that apply.) |
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|Community College Job Corps |
| |
|Four year college Trade school |
| | |
|Military Other: | |
| |
|5 Are you currently in school or training? Yes No |
| |
|6 Did you get extra help in school? Yes No |
| |
| If yes, what kind of help? | |
| |
|Do you have any certificates of training or occupational license? (For example C.N.A., |
|cosmetologist, contractor) Yes No |
| |
| If yes, what kind(s): |
| | |
|8 When did you receive the certificate or license? | |
|Notes: |
|4a. My Employment |
|Describe your last three paid jobs. |
|Job 1 | |Length of time in job: | | Part time |
|Title: | | | |Full time |
|Describe what you did: |
|Did you get any raises or promotions? Yes No Reason for leaving: | |
|What would this employer say about you if I asked for a reference? |
|Job 2 | |Length of time in job: | | Part time |
|Title: | | | |Full time |
|Describe what you did: |
|Did you get any raises or promotions? Yes No Reason for leaving: | |
|What would this employer say about you if I asked for a reference? |
|Job 3 | |Length of time in job: | | Part time |
|Title: | | | |Full time |
|Describe what you did: |
|Did you get any raises or promotions? Yes No Reason for leaving: | |
|What would this employer say about you if I asked for a reference? |
|4b. More Work Experience |
|What jobs have you done from time to time to make extra money? |
| |
|2. What work have you done without pay to help in your church, kids’ school or community? |
| |
|3. What jobs have you done without pay to help family, friends or others? |
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|4. What did you like most about working? |
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|5. What did you not like about working? |
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|Notes: |
|5a. Things I Don’t Like |
|What I don’t like about my life. Check all that apply to your life now. |
| where I live | having others controlling my life |
| what I can buy for myself | depending on friends and relatives |
| what I can buy for my children | where I have to shop |
| the car I have now | not being able to go on a nice vacation |
| not having a car | not being able to help the people who have helped me |
| having to use public assistance | | |
| | Other stuff: |
| people looking down on me | |
| |
|Notes: |
|5b. Things I Would Like |
|What I would like to have in my life. Check all that apply to your life now. |
| better place to live | nice furniture |
| buy things for myself | take a trip by myself |
| buy things for my children | take my children on a vacation |
| get a car | help some of the people who helped me |
| spend my money the way I want to | another thing I would like: |
| | |
| more independence from relatives and friends | another thing I would like: |
| | |
| another thing I would like: | |
| | |
|Notes: |
|6. My Strengths |
|Check all the strengths you have. |
| I have worked | my children are in school or day care |
| I do or have done volunteer work at school, church, or in my community | my family is in good health |
| I have helped friends, family and neighbors | I know people who can help me find work |
| I have someone to watch my children while I look for work | I am active in my church, kids’ school and community |
| I finished high school or got my GED | I have overcome problems |
| I am enrolled in school or trainings | I have good references from past jobs or people in my community |
| I have or can get a ride to look for work | my family and friends will encourage me |
| I have worked for myself | my family is supportive of my working |
| I make a good employee | I have taken college classes |
| I have been able to keep myself and my children safe | |
|Other Strengths: | | |
| | | |
|Another Strength: | | |
| | | |
|One More Strength! | | |
| |
|Notes: |
“I am Awesome!”
|7a. Problems I Have To Solve |
|Problems you have to solve. Check all the problems you have to work on in order to reach your goals. (Include yourself and family) |
| drug and alcohol abuse | health problems |
|an abusive or unsafe situation |child care |
|unstable housing |transportation |
|depression or emotional problems |trouble with reading or math |
|lack of work experience |lack of education |
|bad work record |criminal record or other legal problems |
|fear of partner or household member | |
| | other: | | |
| |
|Notes: |
|7b. Help I May Need |
|What help do you need? What can we do to help you work toward your goals? |
|(Check all that apply) |
| child care assistance | help with drug or alcohol abuse |
| transportation assistance | counseling or help with stress management |
| how to look for work | help to leave an abusive situation |
| education and/or training | help with stable housing |
| getting child support | encouragement |
| help with relationship skills | help with my children’s problems |
| other: | | | other: | | |
| |
|Notes: |
|8. I Am Working or Have Worked With |
|Are you or anyone in your family working with other agencies now or in the past? Yes No |
|If yes, check all that apply: |
| Child Welfare (formerly SCF) | Mental Health Services |
|Corrections/Parole & Probation |One-Stop or Career Centers |
|Disability Services |Senior Services |
|Division of Child Support |Social Security (SSI/SSD/SSB) |
|Domestic Violence Services |Support Groups |
|Drug or Alcohol Services |Vocational Rehabilitation |
|Employment Department |WIA/Private Industry Council |
|Head-Start or Healthy-Start |Women, Infants and Children (WIC) |
|Juvenile Court |Worker’s Compensation (SAIF) |
|Legal Aid |Family Supports and Connections |
| Other: | | | Other: | | |
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| |
|The Department of Human Services (DHS) will not discriminate against anyone. This means DHS will help all who qualify. DHS will not deny help to anyone based on |
|age, race, color, national origin, sex, sexual orientation, religion, political beliefs or disability. You can file a complaint if you think DHS discriminated |
|against you for any of these reasons. |
|“Equal Opportunity is the Law” |
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