Client Self Assessment Survey


Multi-Outcome Client Self Assessment

Collecting this information is an important part of our program. We use it to help you set goals and improve your situation. We also use it to help others by improving our program and communicating the impact of our program. We will protect your privacy and will not share your name or any information that allows someone to identify you outside of the staff who are directly involved in your case or management.

Please imagine a ladder with steps numbered from 1 at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you.

Please select the option that best describes your situation. If you are unsure between two options, choose the lesser/worse of the two.

Prospective Client
Check-In Information

Men & Women

For Mothers with Children