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 |

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|3. |

|      |

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|(     )       |

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|Doctor’s Name |

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|Phone Number |

| |

|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.) |

| |

|Community College Job Corps |

| |

|Four year college Trade school |

| |      |

|Military Other: | |

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|5 Are you currently in school or training? Yes No |

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|6 Did you get extra help in school? Yes No |

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| 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? |

|      |

|4. What did you like most about working? |

|      |

|5. What did you not like about working? |

|      |

|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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