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Quarterly Assessment
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
Submit
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