Quarterly Assessment

Name *

Date *

Case Management and Coaching

I have people in my life that I trust. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I have plans for my future. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I feel like I have support to make life decisions. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I feel alone when making decisions for my family. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I am scared about my future. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

What is your definition of love? *

I feel my life has value & worth *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I am able to give & receive caring/love. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

My support system looks like… *

I have communicated with my Family Case Manager? Daily? Weekly? Monthly? *

I have communicated with my Coach? Daily? Weekly? Monthly? *

I have a close personal relationship with Jesus Christ. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Housing

I feel safe where I currently live. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I currently have stable housing. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

All my children live under the same roof. *

Yes

No

Our home has enough space for our family. *

True

False

Most of my stress is due to unstable housing. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Have you received financial assistance for rent? *

Yes

No

Have you been threatened with eviction in the last 12 months? *

Yes

No

How many times? *

I have moved more than one time in the past year. *

I pay more than 30% of my income towards rent. *

True

False

I have been homeless in the last year? *

Yes

No

How long? *

In 12 months, my goal for housing is: *

Mental Health

I have been to counseling. *

Yes

No

I feel that counseling is benficial. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Consistent counseling has improved my mental health. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Community Groups and Life Skills

I have the opportunity to engage in activites that bring me joy. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I have a creative outlet in my life. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I have a community I feel connected to. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I have friends that equip & encourage me. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

These friends being joy to my life. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I have difficulty maintaining friendships. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

In times of stress I tend to keep to myself. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I can only depend on myself. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I know how much money I spend every month. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I know how to create a monthly budget. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I know the difference between needs and wants. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Employment and Education

I am happy with my job. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Do you like where you are employed or is it just a necessity? *

I like where I work

It is just a necessity

How long have you been employed at your current job? *

Is there room for growth at your current job? *

Yes

No

What is your dream job or desired job? *

How many jobs have you had in the last 3 months? *

Did you graduate from High School or get your GED? *

Yes

No

Are you interested in furthering your education? *

Yes

No

Transportation

I have a reliable vehicle. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I feel safe in my vehicle. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Most of my stress is due to unreliable transportation. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

My vehicle is large enough for my family. *

Yes

No

How long have you had your current vehicle? *

Childcare

I feel safe and secure with my childcare provider. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

I feel my children thrive where they are. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Most of my stress is due to unreliable childcare. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

How many times have you changed your childcare provider in the last 3 months? *

I have a reliable childcare provider. *

1

2

3

4

5

1- Strongly Disagree 2- Disagree 3- Neutral 4- Agree 5-Strongly Agree

Case Management and Coaching

Housing

Mental Health

Community Groups and Life Skills

Employment and Education

Transportation

Childcare

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