Name:
My Self AssessmentName (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 /
1. Do you have any medical problems? Yes No
2. If yes, are you under a doctor’s care for this problem? Yes No
3. / ()
Doctor’s Name / Phone Number
4. 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:
5. Would any of these problems affect your working? Yes No
If yes, which ones would be a problem?
6. 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?
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Name:
3. My Education /1. Check highest grade completed:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 16+
2. Do you have a high school diploma? Yes No
3. Do you have a GED? Yes No
/
4. 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: /
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? /
7 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:
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4a. My EmploymentDescribe your last three paid jobs.
Job 1
Title: / Length of time in job: / Part time
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
Title: / Length of time in job: / Part time
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
Title: / Length of time in job: / Part time
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?
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4b. More Work Experience /1. 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:
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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:
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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:
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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
an abusive or unsafe situation
unstable housing
depression or emotional problems
lack of work experience
bad work record
fear of partner or household member / health problems
child care
transportation
trouble with reading or math
lack of education
criminal record or other legal problems
other:
Notes:
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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:
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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)
Corrections/Parole & Probation
Disability Services
Division of Child Support
Domestic Violence Services
Drug or Alcohol Services
Employment Department
Head-Start or Healthy-Start
Juvenile Court
Legal Aid / Mental Health Services
One-Stop or Career Centers
Senior Services
Social Security (SSI/SSD/SSB)
Support Groups
Vocational Rehabilitation
WIA/Private Industry Council
Women, Infants and Children (WIC)
Worker’s Compensation (SAIF)
Family Supports and Connections
Other: / Other:
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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