Self Assessment DHS 7823 1/09

Name: Self Assessment Tool

Self Sufficiency Programs (use with the DHS 7823A) Temporary Assistance for Needy Families

Name (First, Last, MI): Date : DHS use only - - Case number:

Section A — My family 1. What are the ages of your children? Do your children attend school? Yes No If yes, where?

2. How are your children doing in school? (academically and socially)

3. Check which of the following describes your household: Two parent  Single parent  Teen parent

4. Who would encourage your working?

5. Who would discourage your working?

6. What help do you think you could get from family and friends?

Section B — 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. Do you have any certificates of training or occupational license? (For example C.N.A., cosmetologist, contractor) Yes No If yes, what kind(s): When did you receive the certificate or license? (month/year)

of 4 DHS 7823B (10/11) Name: Section C— My work experience 1. What jobs have you done? (include odd jobs you may have done from time to time to make extra money)

2. Describe what you did in those job experiences?

3. What reasons did you have for leaving those jobs? (list any you can think of about the jobs you mentioned)

4. What was the length of your longest job?

5. What would your employers say about you if I asked for a reference? (list anything you can think of from any of the employers from your job experiences)

6. What work have you done without pay? Example: helping at your church, kids’ school or in your community. Or to help family, friends or others?

7. What did you like most about working?

8. What did you not like about working?

of 4 DHS 7823B (10/11) Name: Section D — 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 people looking down on me other:

Notes:

Section E — 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 other: more independence from relatives and friends other:

Notes:

of 4 DHS 7823B (10/11) Name: Section F — 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:

Section G — You are 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: Agency Past Present Agency Past Present

Child Welfare (formerly SCF) Mental Health Services Corrections/Parole One-stop or Career Centers, and Probation Employment Dept., WIA Division of Child Support Senior and/or Disability Services Domestic Violence Services Social Security (SSI/SSD/SSB) Drug or Alcohol Services Support groups Family Support and Connections Vocational Rehabilitation Head-Start or Healthy-Start Women, Infants and Children (WIC) Juvenile courts Worker’s Compensation (SAIF) Legal Aid 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”

of 4 DHS 7823B (10/11)