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.

First Name

Last Name

Sex

Male Female

If other, please specify

Are you a former client or is this your first time?

Former Client First Time Client

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.

On which step of the ladder would you say you personally feel you stand at this time?

On which step do you think you will stand about five years from now?

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

Family

My relationship with my family causes me more harm or stress than good I have no contact with family or no family My relationship with my family is a balanced mix of good and bad My relationship with my family is occasionally stressful, but good overall My relationship with my family is a major source of strength in my life

Friends

I have no one I would consider a friend I have some friends, but I don’t think I could count on them to support me in a crisis I have some friends who I think I could count on for support, but I don’t talk to them often I have some friends who I think I could count on for support and I talk to them often I have close friends who I trust completely and talk to frequently

Support System

I have no one who would help me in a crisis and I am unaware of any community resources I have no one who would help me in a crisis and I am aware of some community resources I have 1-3 people who would help me in a crisis and I am aware of community resources I have 3-5 people who would help me in a crisis and I am aware of community resources I have 5+ people who would help me in a crisis, I am aware of community resources, and I am able to support others in their crises

Community Involvement

I do not know my neighbors and I do not participate in community events (local celebrations, service projects, PTA meetings, local government meetings, neighborhood associations, etc.) I occasionally participate in community events, but I do not know my neighbors I know a few of my neighbors but I do not participate in community events I know a few of my neighbors AND I occasionally participate in community events I know many of my neighbors and I am an active participant in community events

Volunteerism

I rarely volunteer with any church, nonprofit, or community organization I volunteer a few times a year I volunteer about once a month I volunteer two-three times a month I volunteer weekly

Church

I do not attend church I attend church a few times a year I attend church monthly I attend church most weeks I attend church most weeks and support my church as a regular volunteer

Housing

I camp or live in a shelter I live with family or friends or in a transitional home with supportive services I live in permanent housing provided or subsidized by the government I rent a home or apartment (my name is on the lease) I own or am making payments on a home

Living Situation

My home is not safe or is very unhealthy (threats of violence, mold, secondhand smoke, etc.) My home is somewhat healthy, but not too safe My home is somewhat safe but not too healthy My home is fairly safe and healthy My home is very safe and healthy

Employment Documentation

I have none of the three main documents I need to be employed (birth certificate, Social Security card, and license/state ID, or immigrant equivalent documents) and no plan to get them I don’t have the documents I need to be employed, but I have begun the process to get them I have one of the documents I need to be employed I have two of the documents I need to be employed I have my birth certificate, Social Security card, and license/state ID, or immigrant equivalent documents

Education

I do not have a high school degree or equivalent I have a high school diploma or equivalent exam (GED, HiSET, or TASC) I have some college or technical education, but no degree or certificate I have an associates degree or vocational certification I have a bachelor’s degree or higher

Employment

Unemployed or do not work with no significant income Not working, but receive a pension, social security, disability benefits, or some other un-earned income Employed Part-Time Employed Full-Time, but dissatisfied with my current employer Employed Full-Time and I would like to stay with my current employer for the foreseeable future

Income

No significant income, meeting basic needs is nearly impossible My income is not enough to consistently meet basic needs My income meets basic needs, but can’t always cover emergencies My income meets basic needs and covers emergencies, but isn’t enough to save much My income meets my needs, cover emergencies, save for the future, and some extra

Financial Resilience

I have no significant emergency fund and no written budget I have a basic emergency fund of ($1000) but no written budget I have a written budget that I stick to, but no emergency fund I have a written budget that I stick to and an emergency fund ($1000) I have a written budget that I stick to and a large emergency fund of $3,000+

Debt

I have recently declared bankruptcy or plan to soon I am behind on multiple debt payments and am not sure if I will be able to catch up I have a lot of debt and occasionally fall behind on a payment I have a manageable amount of debt, but it interferes with my savings and other goals I am debt free, or only have a mortgage

Food

I rely almost entirely on free or low-cost food I can purchase some food, but rely on monthly food assistance like SNAP or a food pantry I can meet my basic food need with some occasional assistance I can afford a simple, healthy diet without assistance I can afford a healthy diet with some treats without assistance

Health Insurance

I have no way to pay for medical care I am reliant on Medicaid I have partially subsidized health insurance I have private health insurance, but I have difficulty paying the deductible and co-pays I have private health insurance and I can afford paying the deductible and co-pays

Heath

Very poor. I have major health issues that severely limit me Poor. I have some moderate health problems that limit me occasionally Fair. I have a few health problems, but they are generally under control Good. I have no health problems, but I’m not in the best shape Excellent. I have no health problems, and I’m in good shape

Sobriety

I am currently addicted to drugs or alcohol I am trying to become free from drugs and alcohol, but I relapse frequently I have had a relapse in the past year, but am currently sober I have been addicted to drugs or alcohol but I have a good support system have not relapsed in the past year I have not been addicted to drugs or alcohol in the past ten years

Tobacco

I currently smoke 10+ cigarettes a day I currently smoke 1-10 cigarettes a day I smoke cigarettes a several times a month or use other tobacco products I currently vape or use tobacco-free nicotine replacement products I am tobacco free

Stress and Anxiety

My stress level/anxiety is extremely high My stress level/anxiety is high My stress level/anxiety is manageable My stress level/anxiety is generally low My stress level/anxiety is very low

Emotions

I feel like my emotions are often out of control I feel like my emotions are sometimes out of control I do not share my emotions and I keep them under control I can share my emotions fairly well and they are rarely out of control I can manage and share my emotions effectively

Fulfillment

I don’t think I have any talents/special abilities I am becoming aware of some talents/special abilities I know my talents/special abilities, but I rarely get to use them I know my talents/special abilities, and I sometimes get to use them I know my talents/special abilities, and I use them frequently

Spirituality

I am fairly confident God does not exist I have no relationship with God or I’m unsure if God exists I believe God exists, and I’m beginning to learn more about Him I pray or read the Bible often I have a growing relationship with Christ, which helps me make life decisions

Parenting

I don’t know anything about parenting I know a few things about parenting, but my kids aren’t doing too well I have some parenting skills, but my kids get into trouble sometimes I have solid parenting skills and my kids are doing fairly well I have solid parenting skills and my kids are doing exceptionally well or I don’t have kids at home

Childcare

I need childcare to meet my goals but have none I have some access to the childcare I need to meet my goals, but it is subsidized I can afford the childcare I need, but it is not high quality I can afford most of the childcare I need and the quality is acceptable I can afford all of the childcare I need and it is good quality, or I do not need any

Legal Involvement (Criminal)

I have outstanding warrants or tickets I have current charges or a trial pending I am currently on probation or parole I have completed probation or parole in the past 12 months, but have no other issues I do not have any current criminal issues

DRM Representative Filling Out This Form

Client Self Assessment Survey

Multi-Outcome Client Self Assessment

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Men & Women

For Mothers with Children

Client Self Assessment Survey

Multi-Outcome Client Self Assessment

Get in Touch

Who We Are

How We Help

Get Involved

Mission Media

Ways to Give

Prospective ClientCheck-In Information

Men & Women

For Mothers with Children

Prospective Client
Check-In Information