Bridges to Youth Self Sufficiency Project

Questionnaire

Participant Name: ______Age: ______Phone: ______

Address: ______Date of Birth: ______

School: (if applicable) ______Social Security Number: _____-____-______

Parent/Guardian Name: ______Phone: ______

Address: ______Email: ______

  1. Are you a U.S. citizen or legally eligible to work in the U.S.?

Yes____ No____

  1. What type of work experience have you participated in? (Please check all that apply)

None____ Paid____ Non-paid____ Volunteer Work____ Community Service____

(Please attach resume)

  1. Are you currently employed?

Yes____ No____ If yes, where? ______

If no, do you want part time (at least 20 hours per week) or full time work? (Please circle your preference)

  1. If you are currently employed, how many hours do you work per week? How many hours is a job coach with you?

Hours per week: ______Job coach hours per week: ______

  1. Are you currently receiving accommodations or using adaptive equipment at work? If not, would you be more successful with this additional support? What specifically do you need?

______

______

  1. Do you feel that you are able to advocate for yourself? Can you explain to others your personal strengths and weaknesses?

Yes____ No____

  1. Do you currently receive SSI/SSDI benefits? If under age 18, who is your legal guardian? If over age 18, who is the responsible party that provides for or assists with your needs?

Yes____ No____ Legal Guardian/Responsible Party ______

  1. Are you currently receiving Medi-Cal/Optical Benefits?

Yes____ No____

  1. Are you currently a client of the Department of Rehabilitation and/or Regional Center?

Yes____ No____ (If you answered ‘Yes’, please circle the name of the agency.)

  1. Do you currently use public transportation to get around (for example, bus)?

Yes____ No____

  1. Are you currently enrolled or do you plan to attend post secondary training i.e., adult education, community college, ROP, etc.?

Yes____ No____ (If you answered ‘Yes’, please circle the type of training.)

  1. What is your current living situation?

On my own____ With parents____ Other______

  1. How will your living arrangement change after leaving school?

On my own____ With parents____ Other______

(If you will be living on your own, will it be with or without support? Please circle your answer.)

  1. Do you have a goal for yourself? Where do you see yourself 5 or 10 years from now? Where will you be living? Where will you be working?

______

______

______

______

  1. What support/assistance do you feel you need to reach your goal?

______

______