Self Sufficiency Matrix Rating Sheet
Self Sufficiency Matrix Rating Sheet
Self Sufficiency Matrix (SSM) assessments are made on all adult and unaccompanied youth clients. Assessments are made at the time of entry to a program, every 90 days thereafter, and at exit from the program.
Last Name: / First Name: / Middle Name: / Suffix (Ex: Jr.):Social Security Number: / Date of Birth (MM/DD/YYYY):
Date of Assessment:
Type of Matrix: / o Entry / o Interim / o Exit*
* An Exit SSM assessment is entered in HMIS before ending the enrollment and terminating the application.
Refer to the Utah Self Sufficiency Matrix and make an assessment of the client’s level of self sufficiency for each domain circling a rating between 1 and 5, or N/A when applicable (for example, Childcare is N/A’d for adults with no children). All domains require an assessment.
Domain / Rating / Domain / RatingIncome / 1 / 2 / 3 / 4 / 5 / Mental Health / 1 / 2 / 3 / 4 / 5
Employment: / 1 / 2 / 3 / 4 / 5 / Substance Abuse / 1 / 2 / 3 / 4 / 5
Housing / 1 / 2 / 3 / 4 / 5 / Family Relations / 1 / 2 / 3 / 4 / 5
Food / 1 / 2 / 3 / 4 / 5 / Mobility / 1 / 2 / 3 / 4 / 5
Childcare / 1 / 2 / 3 / 4 / 5 / NA / Community Involvement / 1 / 2 / 3 / 4 / 5
Children’s Education / 1 / 2 / 3 / 4 / 5 / NA / Safety / 1 / 2 / 3 / 4 / 5
Adult Education / 1 / 2 / 3 / 4 / 5 / Parenting Skills / 1 / 2 / 3 / 4 / 5 / NA
Legal / 1 / 2 / 3 / 4 / 5 / Physical Health / 1 / 2 / 3 / 4 / 5
Health Care Coverage / 1 / 2 / 3 / 4 / 5 / Support Network / 1 / 2 / 3 / 4 / 5
Life Skills / 1 / 2 / 3 / 4 / 5
SSM assessment performed by (Case Manager):
HMIS Data Entry Information
Entered in HMIS by: / Date:5/10/06